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ColumtJia ®nibergitj> .^ 
in tfje Citp of i^ctti ^ork T" 

^cfjool of Bcntal anb (J^ral ^urgS^ 




J^eference l^ibrarp 



THE 

PRINCIPLES AND PRACTICE 

OF SURGERY 



Digitized by the Internet Archive 

in 2010 with funding from 
Columbia University Libraries 



http://www.archive.org/details/principlespracti1921haub 



THE 

PRINCIPLES AND PRACTICE 

OF SURGERY 



BY 

HERMAN A. HAUBOLD, M.D. 

CLINICAL PROFESSOR IN SURGERY, 

NEW YORK UNIVERSITY AND 

BELLEVUE HOSPITAL 

MEDICAL COLLEGE, 

NEW YORK 

VOLT'ME II 




WITH 411 ILLUSTRATIONS 



D. APPLETON AND COMPANY 

NEW YORK LONDON 

1921 



COPYBIGHT, 1921, BY 

D. APPLETON AND COMPANY 



KD3 



PRINTED IN THE DNITED STATER Or AMERIPA 



CONTENTS 



PART VITT 
Surgery or-^ Dkformities 

CHAPTER PACE 

I. Congenital Deformities 1331 

Defoniiities Due to Atypical Development 1331 

Deforrrrities Due to faulty Position of the Fetus 1331 

Deformities Due to Intra-uterine Diseases 1331 

Deformities Developed as a Result Dnrinsr Delivery 1331 

Deformities Acquired After Birth 1332 

Bloodless Operations 1333 

Redressmeut of Arthrojienous Contractures 1333 

General Dansrers of Redressmeut 1333 

Infraction 1334 

Epiphyseolysis ' 1334 

General Considerations Resrardinu' Bloody (Operations of Ortho- 
pedic Suraery 1335 

Technic of Orthopedic Dressings 1335 

Orthopedic Appliances 1337 

Massage 133S 

Gymnastics 1339 

Mechanotherapy 1341 

Heliothera]iv 1341 

Heat ....." 1342 

II. Malformations, Developmental Deformities and Softenins: of 

the Bones 1344 

Malformations Due to Developmental Defects 1344 

Dwarfism (^Microsomia or Nanosomia) 1344 

Developmental Defects 1345 

Amelia 1345 

Phocomelia 1345 

Peromelia 1345 

Micromelia 1345 

Perodactylia 1345 

Brachydactylia 1345 

Ectrodactylia 1345 

Congenital Defects of Single Bones — Defects of the ri)per Arm 1345 



CONTENTS 

CHAPTER PAGE 

Defect of the Radius 1346 

Ulnar Defect 1346 

Defective Femur 1346 

Tibial Defects 1347 

Forked Hand and Cloven Foot 1347 

Fission and Deduplication 1348 

Fusion Deformities 1348 

Malformations Due to Faulty Posture of the Fetus. . . . 1349 

Malformations Due to Excessive Development 1349 

Giantism (Macrosomia) 1350 

Developmental Disturbances of Bones 1350 

III. Congenital Lvixations and Contractures 1354 

Congenital Dislocation of the Hip 1354 

Congenital Luxation of the Knee Joint 1361 

Congenital Luxations of the Shoulder, Elbow and the 

Hand 1362 

Congenital Contractures 1362 

IV. Torticollis 1363 

Torticollis Developing After Birth 1366 

1. Cicatrical Torticollis 1366 

2. Habitual Torticollis 1366 

3. Rheumatic Torticollis 1366 

4. Torticollis after Infectious Diseases 1366 

v. Kyphotic Anomalies of Posture 1308 

Kyphosis 1368 

Degenerative Curved Back L368 

Rachitic Curved Back 1368 

Relaxation Ronnd Back 1368 

Occupational Round Back 1369 

Scoliosis — Lateral Curvature of the Spine 1370 

Congenital Scoliosis 1370 

Rachitic Scoliosis 1371 

Habitual Scoliosis 1371 

Paralytic Scoliosis 1371 

Static Scoliosis 1371 

Cicatrical Scoliosis 1371 

Deformities of the Thorax 1378 

Chicken Breast 1378 

Funnel Breast 1379 

Cicatrical Deformities 1379 

VI. Deformations of the Upper Extremity 1380 

Congenital Elevation of the Shoulder 1380 

Acquired Elevation of the Shoulder 1380 

Scaphoid Scapula 1381 

Rlieumatic Slioulder 1381 

Obstetrical Paralysis of the Ann 1^81 



CONTENTS vii 

IHAPTER PACE 

Spontaneous Subluxation of tlie Tlaiul 1383 

Dupuytren's Conti-actiou 1383 

Knu'ken berg's Finger Contracture 1383 

Acquired Contractures 1383 

Tendon Slieath Stenosis 1383 

VIT. Deformities of tlie Lower Extremities 1385 

Coxa Vara 1385 

Coxa Valga 1388 

Genu Varum .' 1388 

Genu Valg-um 1389 

Genu Recun^atum 1392 

Deformities of tbe Foot 1SP3 

Flat Foot 1893 

Club Foot 1399 

-Pes Cavus — Hollow Foot 1404 

Pes Equinus 1404 

Pes Calcaneus 1406 

Pes Adductus, or Metatarsus Varus 1408 

Hallux Valgus 1408 

Hammer Toe 1409 



PART TX 

Regional Surgery of the Spine 

T. General Surgical Conditions , . 1413 

Injuries of the Spine Other Than Fractures and Disloca- 
tions 1413 

XL Spina Bifida 1422 

TTT. Spondylitis 1433 

IV. Injuries of the Spinal Cord 1448 

Concussion of the Spinal Cord 1448 

Hematomyelia 1449 

Contusion of the Spinal Cord 1450 

Laceration of the Spinal Cord 1450 

The Symptomolog'y of Complete and Partial Cord 

Lesions 1450 

Stab and Gunshot T\''ounds of the Spine and Contents 

of the Spinal Canal 1457 

V. Spinal Tumors 1462 

VI. Surgery of the Spinal Roots 1466 

VII. Laminectomy — Chordotomy 1472 

Decompressive Laminectomy 1476 

Chordotomy 1476 



CONTENTS 

PART X 

Surgery of the Head 

;hapter page 

T. The Scalp , 1481 

"Wounds of the Scalp 1481 

Tumors of the Scalp 1482 

The Cranium 1486 

Fractures of the Skull 1486 

Fissured Fractures 1487 

Comminuted Fractures 1487 

Perforated Fractures 1488 

Incised, Punctured and Gunshot Wounds of the Skull 1497 

Diseases of the Skull 1499 

Tumors of the Cranial Bonos 1499 

Lues of the Bones of the. Skull 1500 

Tuberculosis of the Skull 1500 

Acute Osteomyelitis of the Skull 1500 

11. Surgery of the Brain, Its Membranes and Vessels 1502 

Cephaloeele 1502 

Conijenital Hydrocephalus 1503 

Concussion of the Brain 1504 

Compression of the Brain .' 1506 

Injury of the Intracranial Vessels 1509 

Injuries of the Cranial Sinuses 1512 

III. Contusions and "Wounds of tlie Brain 1516 

Contusions of the Brain 1516 

Wounds of the Brain 1518 

Cerebral Localization 1520 

IV. Traumatic Meninaitis 1528 

V. Hernia of the Brain 1530 

VT. Abscess of the Brain 1532 

Acute Traumatic Cortical Abscess 1532 

Chronic Traumatic Abscess 1533 

Otitic Brain A))scess 1535 

Rhinoaenous Brain Abscesses 1537 

Abscesses Beneath Ulcerative Processes 1537 

Metastatic Abscesses 1538 

VTI. Thrombosis of the Intracranial Sinuses 1540 

Infectious Sinus Thrombosis L540 

VIII. Epilepsy and Its Sur.sical Treatment 1545 

TX. "Mental Diseases followinir Cranial Injuries and the Sur- 

sical Treatment of !Mental Diseases 1550 

X. The Sursrical Treatment of Brain Tumors 1554 

XL The Sursery of the Hypophysis Cerebri 1560 

XII. The Technic of Trephinine: Brain Puncture, Resection of 
the Skull, Craniectomy, Cranioplasty and Dura- 

plasty 1563 



CONTENTS 



PAGE 



Simple Drilling; of the Skull 1563 

Sinii)le Resection of tlie Skull 1564 

Osteoplastic Resection of the Skull 1564 

The C'losuie of Cranial Defects 1566 

Duiaplasty 1567 

XIII. Craniocerebral Toi)o.uraphy 1569 

XIV. Surgery of the Ear 1573 

Coni>enital Malformations of the External Ear 157.3 

Injuries of the Ear 1574 

Inflammation of the Ear Drum 1577 

Acute Otitis Media 1577 

Inflammation of the Accessory Pneumatic Sjiaces 1579 

New Growths of the Ear 1584 

PART XI 

Surgery of the Face 

I. Congenital Malformations 1591 

Development of the Face 1591 

Individual Cleft Formation 1592 

Clefts of the Upper Lip 1592 

Clefts of the Nose 1594 

Oblique Facial Clefts 1594 

Transverse Facial Clefts 1595 

The Operative Relief of Cleft Formations 1595 

Cleft Palate (Uranoschisma) 1599 

II. Injuries of the Face 1005 

III. Plastic Suraery of the Face 1609 

Rhinoplastv 1609 

Cheiloplasty 1613 

Stomatoplastv 1615 

Meloplasty . * 1615 

Plastic Replacement of Hairy Areas 1617 

IV. Neuralgias of the Head " 1619 

V. Surgery of the Salivary Glands 1628 

Injuries of the Salivary Glands 1628 

Foreign Bodies and Calculi 1630 

Acute Inflammatory Processes of the Salivary Glands.. 1631 

Actinomycosis — Tuberculosis — Lues 1633 

Salivary Cysts 1633 

Tumors of the Salivary Glands 1634 

Total Extirpation of the Parotid and the Sul)maxillary 

Glands ". 1636 

VI. Diseases of the Teeth and of the Gums 1638 

Caries of the Teeth 1638 

Diseases of the Gums 1639 



CONTExVrS 



CHAPTER PAGE 

VII. Tumors of the Jaws 1641 

Odontogenous Maxillary Tumors 1641 

Epulis: Epulis Fibromata and Epulis Sarcomata 1642 

Sarcoma 1642 

Carcinoma 1643 

Hj'perotoses 1644 

Tuberculosis of the Jaws 1644 

Actinomycosis of the Jaws 1645 

Syphilis of the Jaws 1646 

Total Resection of the Superior Maxilla 1646 

Resection and Exarticulation of the Lower Jaw 1648 

YIII. The Surgery of the Nose and Its Accessory Sinuses 1651 

Malformation of the Nose 1651 

Injuries of the Nose 1651 

Deviations and Spurs of the Septum 1652 

Foreign Bodies in the Nose 1652 

Inflammations of the Accessory Nasal cavities 1652 

Empyema of the Maxillary Antrum 1654 

Empyema of the Frontal Sinus 1656 

Empyema of the Ethmoid Cells 1657 

Empyema of the Sphenoid Cells 1657 

Ulceration and Infectious Granulomata 1658 

Nasal Hemorrhage 1659 

Benign Tumors of tlie Nose 1659 

Malignant Tumors of the Nose 1660 

IX. The Surgery of the Mouth 1663 

Malformations and Congenital Affections of the Mouth. 1663 
Wounds, Burns, Scalds, and Chemical Cauterization of 

the Buccal Mucosa 1664 

Lues of the Mouth 1666 

Tuberculosis of the Mouth 1666 

Actinomycosis of tlie Mouth 1668 

Phlegmonous Glossitis 1668 

Hemangiomata of the Mouth 1670 

Lymphangiomata of the Mouth 1670 

Macroglossia 1671 

Mucous Cysts of the Mouth 1672 

Ranula 1672 

Dermoids of the Mouth 1674 

Solid Non-carcinomatous Tumors of the Tongue 1674 

Carcinoma of the IMouth 1675 

X. Surgery of the Pharynx 1681 

Malformations of the Pharynx 1681 

Inflammatory Diseases 1681 

Phlegmonous Tonsillitis and Peritonsillitis 1681 

The Retropharyngeal Abscess 1683 



CONTEXTS xi 

PACE 

Hypertropliy of the Pharyngeal Tonsil 1084 

Ilypertrojjhy of the Palatine Tonsil 1034 

Lues, Tuberculosis, Lepra, Scleroma, and Glanders of the 

Pharynx 1G86 

Injuries and Foreign Bodies in the Pharynx 1087 

Stenosis and Distortions of the Pharynx 1088 

Benign Tumors of tlie Pharynx 1089 

Carcinoma of the EpipharjTix, Mesopharynx, and Hypo- 
pharynx 1093 

Operative Exposure of the Pharj-nx 1094 



PART XII 

Surgery of the Xeck 

I. Malformations of the Xeck 1701 

Congenital Fistulae and Cysis of the Xeck 1701 

Branchiogenic Outgrowths of the Skin of the Xeck 1703 

Cervical Ribs 1703 

IL Injuries of the Xeck 1705 

Burns 1705 

Fractures of the Hyoid Bone 1705 

Injuries of the Arteries of the Xeck 1705 

Injuries of the Veins of the Xeck 1706 

Injuries to the Thoracic Duct 1706 

Injuries to the Xerves of the Xeck 1707 

Aneurisms of the Xeck 1707 

III. Diseases of the Xeck 1709 

Acute Phlegmons and Abscesses 1709 

Chronic Inflammatory Processes of the Xeck 1710 

Lues of the Xeck 1713 

Actinomycosis of the Xeck 1714 

IV. Tumors of the Xeck 1716 

Cystic Tumors 1716 

Solid Tumors of the Xeck 1717 

Malignant Tumors of the Xeck 1719 

V. Surgery of the Larynx and Trachea 1722 

Malformations of the Larynx 1722 

Concussion of the Larynx 1724 

Fracture of the LarjTix and Trachea 1724 

VI. "Wounds of the Larynx and Trachea 1726 

Gunshot "Wounds 1726 

Incised and Stab Wounds 1726 

Burns 1727 

VII. Foreign Bodies in the Air Passages 1728 



CONTENTS 

CHAPTEK ^^(.g 

VIII. Inflammatory Diseases, Stenoses and Neuroses of the 

Larynx and Trachea 1732 

Edema Laryngis: Laryniiitis Siihmucoria 1733 

Laryngeal Perichondritis 1734 

Specific Inflammations of the Larynx and Tiacliea 1735 

Stenoses of the Larynx and Trachea 1737 

Fistulae of the Larynx and Trachea 1739 

IX. Tumors of the Lar3nx, Trachea, and Primary Bronchi 1741 

Benign Tumors of the Larynx 1741 

Malignant Tumors of the Larynx 1742 

Tumors of the Trachea 1745 

Tumors of the Primary Bronchi 1746 

X. Operations on the Air Passages 1747 

Tracheotomy 1747 

Tamponade of the Trachea 1752 

Laryngotomy 1752 

Laryngectomy 1754 

XL Surgery of the Tryroid Gland 1757 

Goiter 1757 

Inflammations of the Normal Thyroid Gland and of 

Goiter *. 1768 

Tumors of the Thyroid Gland 1769 

Cretinism 1770 

Exophthalmic Goiter 1771 



PAKT XTTT 

The Surgery of the Thymus Gland 

Diseases of the Thymus Gland 1779 

Thymus Hyperplasis 1779 

Circulatory and Inflammatory Disturbances of the 

Th>Tnus Gland ." ' 1781 

Tumors of the Thymus Gland 1781 

Thj'mus Gland and Graves' Disease 1782 

Operations on the Thymus Gland 1782 



PART XTY 

The Surgery of the Esophagus 

I. Examination of the Esophagus 1787 

Congenital Malformations of the Esophagus 1789 

Injuries of Esophagus 1789 

Foreign Bodies in the Esophagus 1791 



CONTENTS xiii 

PAGE 

Tnflaniniatory Diseases of the Esophagus 1796 

Strictures of the Esophagus 1797 

The Operative Treatment of Esophageal Strictures 1799 

Dilatation of the Esophagus 1802 

Divoi-ticula of the Esophagus 1803 

Tumors of the Esophagus 1805 



PART XV 

Surgery of the Thorax 

T. Injuries and Diseases of the Thoracic Wall 1811 

Injuries of the Thorax 1811 

Contusion of the Thorax 1811 

Concussion of the Thorax 1812 

Inflammatory Diseases of the Thoracic Skeleton 1813 

Hematogenous Osteitis and Periostitis of the Rihs and 

Sternum 1813 

Intercostal Neuralgia 1814 

Tumors of the Thoracic Wall 1815 

The Technic of Resection of the Thoracic Wall 181fi 

II. Pneumothorax 1818 

III. Penetrating Wounds of the Thorax 1821 

Gunshot Wounds of the Thorax 1821 

Surgical Diseases of the Pleura 1828 

New Growths of the Pleura 1834 

IV. Surgery of the Lung 1836 

Surgical Diseases of the Lung 1836 

V. The Surgery of the Mediastinum 1843 

Injuries to the Mediastinum 1843 

Mediastinitis 1843 

Tumors of the Mediastinum 1844 

VI. Operations on the Thorax 1846 

Paracentesis of the Thoracic Cavity 1846 

Artificial Pneumothorax 1846 

Thoracotomy 1848 

Decortication of the Lung 1851 

Thoracoplasty 1852 

Pneumectomy 1853 

Anterior Mediastinal Thoracotomy 1853 

Posterior Mediastinal Thoracotomy 1854 

VII. The Diaphragm ' 1856 

Congenital Malformations 1856 

Injuries of the Diaphragm 1856 

Hernia of the Diaphragm 1857 



t CONTEXTS 

CHAPTEJt PAGE 

VIII. Surgery of the Pericardium and Heart 1859 

The Pericardium 1859 

Paracentesis of the Pericardium 1859 

Pericardiotomy 1859 

Cardiolysis . . .• 1861 

Wounds of the Pericardium 1861 

Foreign Bodies in the Pericardium 1861 

The Heart 1861 

Wounds of the Heart 1861 

Foreign Bodies in the Heart 1865 

IX. The Surgery of the Breast 1866 

Malformations of the Breast 1866 

Diseases of the Breast 1866 

Benign Tumors of tlie Breast 1870 

Adenofibroma 1870 

Cysto-adenoma 1870 

Cysts of the Breast 1871 

Malignant Tumors of the Breast 1872 



PART XVI 

The Surgery of the At-domen" 

I. Surgery of the Abdominal Wall 1885 

Injuries of the Abdominal Wall 1885 

Diseases of the Abdominal Wall 1886 

Tumors of the Abdominal Wall 1887 

Inflammations of the Xavel 1S89 

II. Surgery of the Peritoneum 1890 

Peritonitis 1890 

Diffuse Peritonitis 1891 

Circumscribed Peritonitis 1899 

Subphrenic Abscess 1900 

Chronic Exudative Peritonitis 1904 

Chronic Adhesive Sclerosing Peritonitis 1904 

Tuberculous Peritonitis 1905 

Injuries of the Peritoneum 1906 

Tumors of the Peritoneum, Subperitoneal Tissues, 

Omentum and Mesentery Ascites 1910 

III. Operations on the Stomach and Intestines 1912 

Complications and Sequelae of Abdominal Operations. . . . 1914 

Abdominal Incisions 1916 

Operations on the Stomach ; 1917 

Perforated Duodenal Ulcer 1919 

Pyloroplasty 1919 

Posterior Gastro-Enterostomy 1919 



CONTENTS 



PACE 



AiiU'iior (iaslro-Enterostoniy 1923 

Exi'isiou of (lastric Ulcer 19-'' 

Houriilass Stomach l-^-'^O 

Resection of the Stomach for Cancer l^-'^O 

Gastrostomy 1^'^^ 

Jejunostomy ^-''^^ 

Intestinal Suture l^-^^ 

Enterotoniy and Enterostomy 1^41 

Colostomy" • • • ; • ^^^-^ 

Entero-Anastomosis, Lateral Anastomosis, Short Circuit- 

jjjir l.)40 

Enterectomy l'^"*'^ 

Appendectomy l.iob 

Appendicostomy l.H)l 

Intestinal Perforation 1^61 

Intestinal Exclusion _• l^GL 

IV. Injuries of the Stomach and Gut, Foreiim Bodies, Gastric 

and Intestinal Fistulae 19^4 

Injuries of the Stomach and Gut 1964 

ForeigTi Bodies 19^8 

Gastric Fistulae 1969 

Intestinal Fistulae 19^0 

V. ]\Iethods of Examinino: the Stomach and Gut 1973 

VI. Pyloric Stenosis, Hourglass Stomach, Congenital Anomalies 

of the Stomach 1975 

Pyloric Stenosis 19'''5 

Hourglass Stomach 1977 

Congenital Anomalies 1977 

VII. Ulcer of the Stomach and Duodenum 1979 

Ulcer of the Stomach 1979 

Ulcers of the Duodenum 1986 

VIII. Tumors of the Stomach .^ 1989 

Benign Tumors 1989 

Sarcomata 1989 

Carcinoma of the Stomach 1989 

IX. Surgery of tlie Intestines 1995 

Congenital Anomalies of the Gut 1995 

General Considerations Regarding Chronic Intestinal 

Stenosis • 1996 

Ulcers of the Small and Large Gut and Their Complica- 
tions 2000 

Stenosis of the Gut 2001 

Benign Tumors of the Intestines 2004 

Carcinoma of the Intestine 2005 

Mesenteric Embolism and Thrombosis 2006 



CONTENTS 

:HAPrE8 PAGE 

-Ji. Ileus 2000 

Genej'al Considerations Keyardiny the Development and 

Symptoms of Obturation Ileus 2000 

General Considerations Regarding Strangulation of the- 

Intestine 2013 

Occlusion of tlie Gut by Adhesions ..... 2010 

Postoperative Ileus 2018 

Obturation Ileus from Occlusion of the Intestinal 

Lumen 2010 

Strangulation Ileus 2021 

Volvulus 2023 

Intussusception 2025 

XL Appendicitis — Perityphlitis 2027 

The Pathological Anatomy of Appendicitis 2030 

Acute Appendicitis 2030 

Chronic Appendicitis 2034 

Tuberculous Appendicitis 2035 

Clinical Course of Appendicitis 2035 

XII. Hernia 2042 

The Hernial Sac 2042 

The Hernial Contents 2043 

Accessory Hernial Coverings 2045 

The Symptoms and Diagnosis of Hernia 2045 

The Influence of Hernia on the General Condition 2046 

The Treatment of Hernia — Prophylaxis — Trusses.... 2046 

Accidents of Hernia 2050 

The Diagnosis of StrangTilated Hernia 2058 

Strangulation of a Herniated Intestinal Wall (Partial 

Enterocele) . '. 2050 

Strangulated Omentocele 2050 

Clinical Forms of Strangulated Hernia 2050 

Treatment of Strangulated Hernia 2060 

Herniotomy 2062 

Special Hernias — Inguinal Hernia 2065 

Oblique Inguinal Hernia 2065 

Direct Inguinal Hernia 2060 

Rare Forms of Inguinal Hernia 2070 

The Treatment of Ing-uinal Hernias 2071 

Femoral Hernia 2075 

Umbilical Hernia 2078 

Obturator Hernia 2080 

Ventral Hernia 2081 

Lumbar Hernia 2082 

Ischiadic Hernia 2082 

Hernias of the Pelvic Floor 2083 



CONTENTS xvii 

CUAI'TER r.\(;K 

Xlir. Surgery of the Liver 2085 

Aiionialit's ul' l\>siti()ii iiiid Konii ol' the I^ivcr "JOSf) 

Injuries of the Liver 2()S() 

Abscess of the Liver 2()!)() 

Cysts of the Liver 2093 

Chronic Hepatitis 2098 

Tul)er('ulosis of the Liver 2098 

Actiiioniycosis of the Liver 2098 

Tumors of tlie Livci- 2098 

Suriiery of the P.iliary Pa^sa-os 2101 

Inflammation of tlie Biliaiy Passages and (Jallstone Dis- 
ease (Tuberculosis and Actinomycosis of the 

Biliary Passages ar\(\ Idiopathic Cystic Rile Duct) 2104 

Inflammations of the Gallbladder 2112 

Acute Inflammations — Serous Cholecystitis 2112 

Seropurulent Colecystitis 2112 

Phlegmonous Cangrenous Cholecystitis 2112 

Chronic Inflammations 2113 

Inflammations of the Bile Duct 2113 

Acute Inflammation 2113 

Chronic Inflammation 2113 

The Remote Effects of Inflammation of the Biliary Pas- 
sages on Contiguous and Distal Organs 2113 

1. Liver 2113 

2. Stomach and Cut 2113 

3. Peritoneum 2113 

4. Pancreas 2114 

5. Lung and Heart 2114 

The Indications for Operative Treatment .of Cholelithiasis 2114 

Medical Treatment 2114 

Early Operative Measures 2115 

Operative Method 2115 

Tumors of the Gall])ladder and Biliary Passages 2126 

XIV. Surgery of the Sp4een ." 2131 

Splenectomy 2132 

Injuries of the Spleen 2132 

Abscess of the Spleen .' 2134 

Cysts of the Spleen 2135 

Echinococcus of the Spleen 2135 

Tumors of the Spleen 2136 

Tuberculosis of the Spleen 2136 

Splenectomy in Malaria 2136 

Splenectomy for Relief of Leukemia and Pseudoleukemia 2136 

Splenectomy for Relief of Splenomegalia 2137 

Movable Spleen 2137 



ii CONTEXTS 

CUAPTER PAGE 

XV. The Surgery of tlie Pancreas 2139 

Anatomical Considerations 2139 

Physiological Considerations 2140 

Symptoms of Disturbed Pancreatic Function 2140 

. Pancreatitis 2143 

Catarrhal Pancreatitis 2143 

Suppurative Catarrhal Pancreatitis 2143 

Acute Hemorrhagic Pancreatitis 2144 

Cholelithiasis 2145 

Gangrenous Pancreatitis 2145 

Acute Suppurative Pancreatitis 2148 

Chronic Pancreatitis 2149 

Tuberculosis of the Pancreas 2151 

Syphilis of the Pancreas 2151 

Calculi of the Pancreas 2151 

Pancreatic Cysts 2152 

Tumors of the Pancreas 2155 

"Wounds of the Pancreas 2156 



PAKT XVTT 

The Surgery of the Rectum axd the Axus 

I. Anatomical Considerations 2161 

Examination of the Rectum 2162 

II. Malformations of the Rectum 2164 

Malformations of the Anus 2164 

^lalformations of the Rectum 2166 

Operative Treatment 2167 

Foreign Bodies in the Rectum — Injuries of the Rectum 

— Inflammation of the Rectum 2169 

III. Foreign Bodies in the Rectum 2169 

Injuries of the Rectum 2170 

Inflammation of the Anal Skin 2171 

Proctitis and Ulcer of the Rectum 2171 

Specific Inflammations and Ulcers of the Rectum 2173 

lY. Fi^sura Ani — S]iasm of the Anus — - Periproctitis — 

Fistula in Ano 2176 

Fissura Ani 2176 

Periproctitis 2177 

Fistula in Ano 2179 

Y. Narrowing of the Rectum, Strictures, Strictures of the 

Anus 2183 

Narrowing of the Rectum 2183 

Strictures of the Rectum 2183 



CONTEXTS xix 

CHAPTtR PAGE 

VI. neuiorrlioids 2187 

External Hemorrhoids 2188 

Internal Hemorrhoids 2188 

YII. Prolapse of the Rectum 2193 

Etiolo-y 2104 

Symptoms 2195 

Treatment 2196 

VIII. Tumors of the Anus and Kectum 2201 

Tumors of the Anus 2201 

Xew Grow-ths of the Rectum 2201 



PART XVIII 

The Surgery of the Female Organs of Gexeratiox 

[. Congenital and Acquired Malformations 2219 

Hermaphroditism 2219 

Malformation 2219 

Vaginismus 2222 

Surgerv of the External Genitals 2223 

Varix ! : 2223 

Vulvitis 2224 

Bartholinitis 2224 

Abscess of Skene's Glands . , 2224 

Surgery of the Vagina 2227 

Puerperal Injuries 2228 

Cystocele 2233 

Fistulae of the Female Genital Tract 2235 

Vaginitis 2239 

Benign Growths of the Vagina 2239 

Malignant Growths of the Vagina 2240 

Inflammatory Processes Involving the Uterus 2242 

Surgery of the Fallopian Tubes 2254 

Surgery of the Ovary 2258 

PART XIX 

The Surgery of the Genito-Urixary System 

[. Surgery of the Kidneys, Ureters, and Suprarenal Glands. . 2265 

Anatomical Considerations 2265 

^lethods of Examination 2268 

Determination of the Kidney Function 2271 

Congenital Malformation of the Kidneys and Ureters.. 2274 

Injuries of the Kidneys and Ureters 2276 

Diseases of the Kidneys and Ureters 2283 



' CONTENTS 

CHAPTER ,^CE 

Diseases of the Ureters 2325 

Operation ui>on the Kidney's and Ureters 2326 

Xephrectumy; Extirj^ation of *^lie Kidney 2326 

Operations on the Ureters 2331 

Diseases of the Suprarenal (! hinds 2333 

11. The Surgery of the Bladder 2336 

Disturbances of the Bladder 2336 

Methods of Examination 2337 

Congenital ]Malfonnations of the Bladder 2340 

Injuries of the Bladder 2342 

Foreign Bodies in tlie Bladder 2344 

Diseases of the Bladder — Cystitis 2346 

Calculi of the Bladder ' 2351 

Tumors of the Bladder 2356 

III. The Surgery of the Prostate —(Glandula Prostatica) 2361 

Method of Examination 2361 

Congenital Malformations 2361 

Prostatic Cysts * 2361 

Injuries of the Prostate 2362 

Inflammations of the Prostate 2362 

Hypertrophy of the Prostate 2365 

IV. Surgery of the Penis and Urethra 2374 

Congenital ^Malformations 2374 

Inflammations of the Penis 2374 

In jviries of the Penis 2375 

Morbid Conditions of the Pre]:)uce and Penis 2376 

Tumors of the Penis 2378 

Operations on the Penis 2379 

Surgery of the Urethra — -Method of ])assing a Sound. . . . 2382 

Malformations of the Urethra 2383 

Traumatism to the Urethra 2385 

Foreign Bodies in the Urethra 2389 

Inflammation of the Urethra 2391 

Tumors of the Urethra 2393 

Diseases of Cowper's Glands 2393 

Stricture of the Urethra 2393 

v. Surgery of the Testicle and Spermatic Cord 2403 

Undescended and ^Nlisplaced Testicle 2403 

Injuiies and Diseases of the Scrotum 2405 

Injuries and Diseases of the Tunica Vaginalis and 

Spermatic Cord 2406 

Injuries and Dislocation and Torsion of the Testis 2413 

Acute Inflammation of tlie Testis and Epidid\Tnis 2413 

Chronic Inflammation of the Testicle and Epididymis.. 2414 

S])ermatocele and Retention Cysts 2418 

Tumors of the Testicle " 2416 

Diseases of the Seminal Vesicles 2417 



PART VIII 
THE SURGERY OF DEFORMITIES 



CHAPTER I 

GENEEAL CONSIDERATIONS 

Deformities may be classified as : Those developing before birth 
(cong-enital) ; those resulting" from injuries dwring birth; those de- 
velopino: after hirlh from various causes. 

Congenital Defornaties. — Congenital deformities may be divided into 
three groups : Those developing from atypical developme^it of the 
embryonic anlage; those due to abnormal positions of the child; those 
due to diseases developed during ititra-uterine life. 

Deformities Due to Atypical Development. — The group of de- 
formities due to at^vpical development of the embr3'onic anlage may 
be exemplified by the occurrence of six or more toes and b}^ a certain 
form of scoliosis due to the presence of an adventitious vertebra. There 
would seem to be little doubt that the causation in this g'roup of cases 
is attributable to unknown hereditary influences. 

Deformities Due to Faulty Position of the Fetus. — Deformities 
due to faulty position of the fetus form the largest number of the 
various kinds. Their causation is attributable to contracted pelves 
and to lack of amniotic fluid. This faulty development is easier to un- 
derstand in cases in which the child exhibits multiple deformities; with 
single deformities, the explanation is not so clear. In the latter in- 
stances, strangulation by amniotic bands is adduced as the causative 
factor. To this group belong club foot, congenital dislocation of the 
hip, etc. 

Deformities Due to Intra-Uterine Diseases. — Of the diseases de- 
veloping during intra-uterine life which are responsible for deformities, 
those of the skeleton, especially chondrodj^strophia and osteogenesis 
imperfecta, are the most important. 

Deformities Developed as a Result of Injury During Delivery. — This 
group may be exemplified by wry neck which follows rupture of the 
sternomastoid muscle; by cerebral hemorrhage and its seciuential spas- 
ticity of the extremities (Little's disease) ; and by injury to the 
brachial plexus and consequent paralysis of the arm, etc. 

1331 



1332 THE SURGERY OF DEFORMITIES 

Deformities Acquired After Birth. — Rachitis is by far the most fre- 
quent cause of acquired deformities. This disease lessens the resistance 
of the bony structure and is responsible for flat foot, how legs, knock 
knees, coxa vara, cantracted pelvis, scoliosis, and kyphosis. Osteomor 
lacia, the disease which v. Recklinghausen has shown to be identical 
with rachitis (Part V, chap, viii), is responsible for similar deformities 
occurring in the adult, especially in women. The other causes relate 
to infiammatorxj processes of hones and joints (osteomyelitis and 
arthritis) (Bonnet/ Koenig,- Ludloff"), and to paralyses, which 
include those of infants and the group of; paralytic joint contractures 
(Seeligmiiller''). In this category belong also defarmities due to 
apparel, such as hallux valgus (from shoes) ; X-legs (from garters) ; 
wasp waist (from corsets), and talipes equinus (from bedclothes). 
So-called overload deformities, such as flat foot, scoliosis — with and 
without kyphos — are regarded by many observers (see Lange'^' and 
his bibliography) as due to, late forms of rachitis. On the other hand, 
Lange"' seems to have shown that "muscle pull" will cause certain de- 
formities of the foot (hollow foot), and that coxa vara and scoliosis 
may be due to postural causes (policemen, waiter.s, etc.)- Lange' be- 
lieves that in these cases circulatory disturbances are responsible for 
lessening of the resistance of the affected bones, rendering them 
liable to deformation — a view which is supported by the histological 
findings of Julius Wolff.® In the work of the latter, the views of v. 
Volkmann' and Hiitter^ are convincingly controverted in this con- 
nection. Statistical data regarding acquired deformities collected by 
Biesalski are presented by Lange.^ 

The diagnosis of fully developed deformities is usually easy. In the 
early stages of their development great care and systematic examina- 
tions are essential to a correct conclusion. 

Inspection includes comparison with opposite normal parts, the ob- 
servation of the condition of the skin, observation of the presence of 
swelling, and atrophy of the soft parts. 

Palpation is directed toward discovery of differences in temperature 
and the recognition of palpable masses, areas of thickening and cavities. 

Measurem-ents are particularly valuable. While these are taken up 
in connection with special injuries (Fractures, Part IV, chap, iv) 
and deformities, allusion may be made at this time to the Roser®-Nela- 
ton^° line, as indicating the importance of their emplo\-ment. 

The posture assumed hy j&ints and their range of motion are de- 
termined by the use of special instruments or, which is very satisfac- 



GENERAL CONSIDERATIONS 1333 

tory, by tracings on paper of the outline corresponding to the affected 
part. 

The liontgcnogram is of incalcula'ble value in the diagnosis of de- 
formities. However, it must always verify the clinical diagnosis — 
never indicate it. 

Bloodless Operations. — So-called bloodless operative measures of 
relief, such as redressment of arihrogenaus contractures, infraction, 
epSphyscohjsis, and reposition of congenital deformities, are frequently 
employed in orthopedic surgery. 

Redressment of arthrogenous cantractures may be exemplified by the 
bloodless correction of flexion contracture at the knee joint and adduc- 
tion contracture at the hip joint. In children* the hands of the surgeon 
may.be used for this purpose; in adults, however, the use of apparatus 
is necessary. Various more or less satisfactory forms of apparatus are 
used b}' different surgeons and for different purposes. In recent years 
the tendenc}' has been to use especially constructed tables, of which 
the one of Gaugerle, shown in connection with the mechanical treat- 
ment of kyphosis (Fig. 719), may be regarded as a type. Apparatus 
of this sort possesses the advantage of making it feasible to standardize 
accurately the degree of correctional force employed. The work of 
Lange^ depicts several of these -tables, among which his own is not with- 
out merit. 

Redressment of an arthrogenous contracture consists in stretching 
the parts on the concave side of the joint, i. e., the capsule, the tendons, 
and the skin. The procedure is not ivithout da^iger, especially of in- 
jury to the vessels and the nerves. These -are most likely to be trauma- 
tized in redressment of the knee and ankle joints. The vessels are less 
vulnerable than the ner\'es. Sufficient force to cause cyanosis of 

THE part is too GREAT. UnDER NO CIRCUMSTANCES SHOULD A CYANOTIC 

LIMB BE IMMOBILIZED; uudcr tlicse conditions efforts at redressment 
must be abandoned and the open operation resorted to. Another dan- 
ger of redressment in connection with club foot is w^orthy of mention. 
The stretching force may tear the subcutaneous connective tissue and 
the resultant effusion of blood may become infected through an invisible 
rupture in the epidermis, especially when the latter is already in a 
pathological state. For this reason the skin of the part and the hands 
of the surgeon should be cleansed as for operation (Part I, -chap. xi). 
Aside from the local menace involved in redressment, certain general 
dangers must be taken into account. 
The general dangers of redressment of contractures are evinced by 



1334 



THE SURGERY OF DEFORMITIES 



disturbances of cansciousness and convulsions, sometimes resulting in 
death. Since the work of Payr/^ these manifestations have been gen- 
erally ascribed to fat emboli'im. (Part IV, chap. xiii). However, the 
occurrence of convulsions is ascribed by Codevilla^" and others to over- 
stretching of the nerves and to the psychic influences of the manipu- 
lations. Biesalski^^ has 'observed glucosuria, icvev and somnolence 
without convulsions. 

In any event, the surgeon must be reconciled to carrying out a pro- 
longed after treatment, which means the employment of gypsum or 
other apparatus, perhaps for years. This, together with the dangers 
stated and the tendency to recurrence of the deformity in a not incon- 
siderable number of cases, has caused the trend of recent years to 
incline toward the use of the open operative methods of relief. 

Infraction, in modern 
orthopedics, is used mostly 
for the purpose of correct- 
ing rachitic deformities. 
The purpose may be ac- 
complished with the hands, 
the bone being bent over 
the edge of a table. How- 
ever, the infraction is best 
produced by means of suit- 
able apparatus. Many 
forms of apparatus have 
been devised for the pur- 
pose, of which the osteo- 
clast shown in Fig. 634 may be regarded as a type. In orthopedic 
institutions an especially constructed table is generally used. 

Theoretically, the dangers of infraction should "be the same as those 
discussed in connection with redressmcnt (see above) and, clinically, 
this is true. However, strange to say, the complication so greatly 
feared in redressment — fat embolism — rarely occurs in infraction 
(though it should be more frequent), and, as a matter of fact, the 
latter is rarely followed by untoward developments. 

Epiphyseohjsis consists in a bloodless epiphyseal separation. It is 
rarely performed in this country, though Italian surgeons employ it 
for the correction of genu valgum. Its technic is taken up with the 
discussion of genu valgum (p. 1390). 

Reposition is chiefly employed for correction of congenital disloca- 




FiG. 634.— Osteoclast. 



GENERAL CONSIDERATIONS 



1335 




Fig. 635. — Hollow Gypsum Bandage 
Model of the Upper Arm. 



tioii of tlie hip. It is extensively 
discussed in tiie eliapter dealing 
with this subject. 

Ilic (jrncral con aide rat ions re- 
garding bloody operations of 
orthopedic surgery do not differ 
from those discussed in connec- 
tion with operations in general, 
such as asepsis, control of bleed- 
ing, etc., nor from those of gen- 
eral operative procedures (such 
as tendoplasty, osteotomy, ar- 
threctomy, etc.) described in the 
verious parts of this work. 

The tech n i c of orthopedic 
dressings comprises the use of 
the same materials used in con- 
nection with the treatment of 
fractures (Part IV, chap, iv-v) 
and those spoken of in connection with spondylitis. The fact that in 
the class of cases under discussion, dressings and apparatus must 
remain in situ for a long time calls for the use of considerable skill in 
their adjustment and care in the 
selection of material suitable to 
the demands of the individual 
problem. 

For extension, adhesive plaster 
that causes the least irritation to 
the skin should be emploj-ed. 
This, in a measure, is deter- 
mined by the formula of the 
adhesive mixture with which the 
plaster is coated ; one containing 
zinc is regarded as the least irri- 
tating. Before the plaster is ap- 
plied the skin should be cleansed 
and hairy surfaces shaved. 

Tlie starch bandage may be 
used for the immobilization of p,^,^ 636._ positive Gypsum Model of 
the extremities of children. the Upper Arm. 




1336 



THE SURGERY OF DEFORMITIES 



The gypsum dressing is the 
one most frequently selected. 
Unfortunately, serviceable gyp- 
sum bandages are not readily 
obtained in the market and their 
preparation by unskilled hands 
is not satisfactory. Crinoline, 
in which finely powdered gyp- 
sum is incorporated hy hand, 
gives the best results. Before 
application the bandage should 
he immersed for one minute in a 
solutian containing 25gm. of 
powdered alum to a liter of 
water. 

The posture of the patient 
should permit the uninterrupted 
application of the gypsum dress- 
ing and its subsequent harden- 




FiG. 637. — Felt Eemovable Splint 
Moulded Over Positive Gypstjm 
Model of Upper Arm. 



ing without change of position. Until the latter 
is accomplished, the patient should not be trans- 
ported. 

Liquid glass (sodium silicate) reinforcement of 
the g3'psum dressing consists in painting the 
solution of silicate on the gypsum one or two days 
after the latter is applied. The result is a hard, 
firm and very satisfactory dressing. 

The removal of the gypsum dressing is a 

problem of some importance. As a rule, this is 

done by the junior assistant on the house staff, 

who is usually armed with a pocket knife, 

backed by youth and fear of the ''Visiting." 

Special instruments, including an electrically 

driven circular saw, have been devised for this 

purpose. It is desirable that the problem receive 

proper consideration, especially when removable 

apparatus is employed. It is also suggested 

that the use of a proper armamentarium lessens 

Fig. 638.— Hessing's the necessity for frequent renewal of the dress- 
Pelvic and Leg Ap- . 
PARATus. mgs. 




GENERAL CONSIDERATIONS 



1337 



Proper tools are especially necessar}' in the preparation of a model 
of the afflicted part. In the preparation of the (jijpsum model, the 
skin is anointed with vaselin or a similar substance and the gypsmn 
bandage applied in the usual manner, with the part in the corrected 
position. Before the gypsum has ({uite hardened, the dressing is cut 
down and removed and the slight deformations, due to this manipula- 
tion, are corrected by means of a circular gauze bandage. Fig. 635 
shows the condition of affairs {negative model) at this stage of the 

proceedings. The hollow 
negative model is now 
filled with gypsum paste 
and the positive model 
(Fig. 636), in accord with 
which any desired appa- 
ratus may be fashioned, 
is obtained (Fig. 637). 

Figs. 635-637 show a 
Yery simple aspect of the 
problem, which may, how- 
ever, be regarded as illus- 
trating the principle in- 
volved in the procedure. 
Acquaintance with it 
enables the practitioner 
to obtain a replica of the 
afflicted part and send it 
to the technician for the 
construction of the neces- 
sary apparatus, which 
may be conveniently re- 
placed at any time. 
Orthopedic appliances 
are constructed of various materials, including steel, aluminum, 
canvas, leather, etc. The most important factor in their construc- 
tion is that they should conform as closely as possible to the 
outline of the part to which they are adjusted. Appliances of this 
sort are often destined to supplement the action of certain muscles 
and joints or to take their place (artificial hands and legs). Thej^ 
possess the advantage of being easily applied and taken off. Great 
ingenuity has been exercised in their construction. Fig. 638 shows a 




Fig. 639. — Hessing's Scoliosis Corset. 



1338 



THE SURGERY OF DEFORMITIES 



so-called Hessiug^* apparatus used for the purpose of making locomo- 
tion possible in a case of partial paralysis of a lower limb ; and Fig. 
639 shows a scoliosis corset constructed along the same lines. The 
publication of Gocht^^ gives much valuable information in this 
connection. 

Not a few orthopedists use the so-called celluloid mull apparatus of 
Kirch (see Gocht^^), which is light in weight, conforms closely to the 
body, and may be constructed by comparatively unskilled hands. For 
the purpose, three parts 
of celluloid (obtainable 
in the market) are dis- 
solved in ten parts of 
acetone; the solution is 
stirred at intervals for 
twenty-four hours until a 
thick, even mixture is 
formed. The (positive) 
gypsum model (Fig. 636) 
is covered with a thick 
layer of felt or flannel 
and this in turn covered 
with a mull bandage. The 
celluloid-acetone solution 
is applied to the latter 
with a heavy brush and 
the hands ; this is fol- 
lowed by another layer of 
mull bandage and then a 
layer of celluloid-acetone 
solution. From seven to 
ten layers of this sort are 
applied in accord with 

the part to be held in the corrected position. The mixture of celluloid 
and acetone is highly inflammahle. As apparatus constructed in this 
way is not firm enough for use in situations subjected to great strain 
(ambulatory fixation of a lower extremity), Lange" reinforces the 
layers of celluloid-acetone mull with steel wires which he places 
between them. Figure 640 shows a celluloid ''manchette" reinforced 
in this way. 

Massage, in orthopedics, is destined to increase the flow of arterial 




Fig. 



640. — Celluloid-Acetone Splint Eein- 

FORCED with StEEL WIEES. 



GENERAL CONSIDERATIONS 



1339 



blood to, and the flow of venous blood and lymph from, the afflicted 
part. It is employed in five ways, (1) strokintj; (2) rubbiiuj; (3j 
kncadiny; (4) pcrctissiiuj ; (5) vihratiu<j. The first four are per- 
fornieil manually; lor the fifth, an especially constructed mechanism 
is used. 

Gymnastics play an important role in modern orthopedics. Tlie 
object is twofold: Either shortened structures are stretched {passive 
gymnastics) ; or the musculature is to be strengthened {active gym- 
nastics). In addition to this, frequent motion of joints aims at the 
polishing of articular surfaces (when exudates are present) and at the 
coordination of movements (in tabes, writer's cramp, etc.). A detailed 




Fig. 641.- 



Showing the Principle of Passive Gymnastics in Stretching the 
KxEE Joint. 



description of the various apparatus used for the purpose is of course 
impossible here. For this the reader may consult the bibliograpln' at 
the end of the chapter (numbers 16 to 20 inclusive): However, the 
principles involved are shown in connection with contracture of the 
knee joint. 

The object of passive gymnastics is to stretch the shortened muscles, 
tendons, and the capsule on the posterior surface of the knee. For the 
purpose the patient is postured with the abdomen resting upon an 
upholstered table with the leg extending over the edge. A weight 
(sand bag) var\'ing from 200 to 2000gm. is attached to the ankle 
(Fig. 641). The posture is maintained from five to fifteen minutes 



1340 



THE SURGERY OF DEFORMITIES 



at least, three times a day. Special apparatus with elastic tension 
may be used. Figure 642 shows one of tliese used in connection with 
the wrist joint. 




Fig. 642. — Apparatus for Stretching the Wrist 
•Joint. 

Active oymnastics may be accomplished in an efpially simple man- 
ner. The patient is postured as shown in Figure 643. The weight is 




Fig. 643. — Showing the Prinx'iple in Active Stretching of the Knee Joint. 



suspendod from the ankle and is lifted by the extensor muscles of the 
thigh. The latter muscles and the tendons and capsule of the anterior 



GENERAL CONSIDERATIONS 



1341 



portion of the knee may also be j)as.sively stretched with the limb and 
the weight arranged in this way. 

It is of course necessary to arrange the apparatus to conform to the 
afflicted part. The execution of this does not require much ingenuity 
when the principle of the method is borne in mind. The need of 
especially canstructed apparatus in the treatment of ambulatory cases 

has led to the develop- 



ment of so-called 
mechanotherapy which, 
under the impetus given 
by Zander/*^ has de- 
veloped into an art of 
considerable magnitude. 
This apparatus operates 
on the pendulum prin- 
ciple and achieves both 
passive and active gym- 
nastics. Figure 644 
s h o w s the apparatus 
used in connection with 
the mechanical treat- 
ment of the wrist joint. 
It is shown with the 
view of illustrating the 
method. Apparatus for 
the other parts of the 
body may be obtained 
from dealers in surgical 
supplies. 

Heliotherapy occupies 
the most important 
place in light therapy. 
Appreciation of its use 
in orthopedics is due to the efforts of Bernard-^ and Rollier.^^ 
While sunlight contains three constituents useful to light therapy 
(its red and ultrared rays furnish heat; the yellow afford light; and 
the ultraviolet possess chemical activities), all of its rays are used 
for therapeutic purposes. The beneficial effect of heliotherapy in 
diseases of bone is attributed to the mild and prolonged hj'peremia 
it causes. Light treatment is also used in the form of the blue 




rns K/V/'-5Crtf£/)£R CO. N 



Fig. 644. — Zander Wrist Machine. 



1342 



THE SUKGERY OF DEFORMITIES 



light of Richter,-' the quartz lamp, the unilight, and the X-ray. 
Aside from the beneficial effect of light therapy upon bone tubercu- 
losis, it is also of benefit in the local anemia and lymphatic stasis of 
poliomyelitic paralyses in children and in rachitis. 

Heat in the form of haths or dry heat owes its virtue to the hyper- 
emia it provokes and is a useful adjunct in orthopedics. For the pur- 




FiG. 645. — Tyranauer Dry Heat Apparatus for the Hand and Forearm. 



pose of using dry heat at a high temperature (baking) the electric oven 
is largel}^ employed. B}^ encasing the part in layers of absorbent cot- 
ton, which absorbs the moisture given off by the skin, the temperature 
may be raised to 300°F. The apparatus shown in Figure 645 is used 
in treating the hand and forearm. However, apparatus suitable to 
the application of heat to the other portions of the body is readily 
obtainable. The active and passive hyperemia of Bier (Part II, 



GENERAL CONSIDERATIONS 1343 

chap, ix) is also used in the chiss of cases mentioned in connection 
with heliotherapy. 

The therapeutic efficiency of the X-raij in orthopedics is limited to 
its effect upon tuberculosis. 

It is probable that the use of the electric current is restricted to 
maintenance of the nutrition of nerve-s and muscles until anatomical 
regeneration occui*s, and, to a certain extent, to the control of pain. 

BIBLIOGRAPHY 

1. BoNXET. Traite des maladies des artieul., tome ii. 

2. KOEXiG. Zentrl)!. f. Chir. 189.3, No. 52. 

3. LuDLOFP. Grenz. d. Med. u. Chir., 1907. 

4. Seeligmuller. Gerhardt's Handlx d. Kinderkrank., v, H. i. 

5. Laxge. Lehr. d. Orthoped., Jena, 1914. 

6. Julius Wolff. Das Gesetz der Trans, f. der. Knor-hen, Berlin, 1892. 

7. V. VOLKMAXX'^. Virchow's Arch., 1862, xxiv. 

8. HuTTER. ViiThow's Arch., xxv. 

9. RosER. Arch. f. phys. Heilk., 1846, v. 

10. Nelatox. Elements de path Chir., Paris, 1846. 

11. Patr. Chir. Kong., 1912. 

12. Codevilla. Communiea fatta alia soc. med. Chir., Bologna, 1900. 

13. BiESALSKi. Deutsch. med. Woch., 1910, No. 35. 

14. Hessix'G und Hasslauer. Vienna, 1902. 

15. GocHT. Orthop. Teehnik, Stuttgart, 1901. 

16. Zax'der. Die Apparat. f. mechano-therapy, Stockholm, 1893. 

17. Krukexberg. Mech. Heilkunde, Stuttsrart, 1896. 

18. HoHiiAXx. Miinch. med. Woeh., 1906, No. 39. 

19. Goldscheider. Ubungsbehand d. Ataxia, Leipzig, 1899. 

20. BiESALSKi. Arch. f. Orthop. viii, H. i. 

21. Berxard. Heliotherapie im Hochgebira'e, Stuttgart, 1912. 

22. ROLLIER. Sonnenliehand d. chir. Tub., Berlin, 1910. 

23. RiCHTER. Deutsch. med. Woch., 1909, No. 17. 



CHAPTER II 

malfoemations, developmental deformities 
and softening of bones 

As the study of the developmental malformations (tercdology) is 
still an indefinite (luantit^^, double and single malformations are char- 
acterized in accord with their external manifestations. Excluding the 
malformations included in the faulty position of internal organs, the 
so-called tnonstrosities and hermaphroditism, single mMformxitions may 
he divided into two groups : 

1. Those due to defective development, or monstra per defectum, 
which are manifested either by incomplete development of the entire 
hody (hypoplasia or dwarfism) or by the absence of, or the incomplete 
development of, a part or organ (aplasia or agenesis). 

2. Malformatimis due to excessive development, or monstra per 
excessum, which are manifested by abnormal size (giantism) or by 
increase in the numher of various parts. 

The underlying causes of these conditions are already present in the 
fertilized ovum and resemble the regressive and progressive processes 
upon which the organic changes of later life are dependent (see also 
Part VI, Mixed Tumors, etc.). 

Malformations Due to Developmental Defects. — These are the result 
of mechanical interference with growth, of heredity or of primary 
embryonic variations. These causes determine the occurrence of 
aplasia or hypoplasia by interfering with normal development or by 
arresting it at a certain stage. In addition to this, arrest of develop- 
ment is manifested by a failure of coalescence of embryonic segments 
and also by parts arising from a single anlage becoming separated and 
remaining so divided. The latter give rise to division and strangula- 
tion of parts. Atypical or faulty coalescence may occur as the result 
of incomplete differentiation; and, finally, the arrest of development 
may be the outcome of lack of space for the fetus and the abnormal 
position of the extremities during intra-uterine life. 

Dwarfism (Microsomia or Nanosomia). — Genuine, or teratological, 

1344 



DEFOKMITIES AND SOFTENING OF BONES 1345 

dwarfism is a congenital defect of the whole body, originating in the 
first anlage. It is recugnizabk' at birth and 'beeonies niort^ inanifest as 
life advances. Cangenital dwnrfisin must be differentiated from the 
acquired, due to discascvs such as chondrodystrophia and other congen- 
ital systemic diseases of the skeleton — myxedema, cretinism, rachitis, 
etc. 

The distinctive feature of genuine dwarfism is its symmetry, the 
pathological variety being characterized by the asymmetrical propor- 
tioriis of the various parts of the body to one another. 

The Developmental Defects. — Developmental defects are also 
not ascribahle to a single causative factor. They are, of course, not 
readily proved to be due to mechanical influences. It is easy to under- 
stand the causative influence of ha7ids of adhesions between the amnion 
a)id the fetus, which ensnare, strangulate or amputate certain parts. 
The latter are called fetal or spontaneous amputations. The stumps 
of strangulated limbs often show rudimentary fingers and toes. The 
amputated parts are absoBbed. Incomplete strangulation is character- 
ized by deep incisures in the ensnared part. The umbilical cord is 
capable of ensnaring and strangulating the limbs. 

A classification of defects of this sort is offered by Riedinger,^ as 
follows : 

Amelia — complete absence of the upper and lower extremities. 
Abrachius — absence of the upper extremities. Apus — ab- 
sence of the lower extremities. Monobrachius — absence of one 
upper extremity. Monopus — absence of one lower extremity. 

Phocomelia (seal limbs) — rudimentary extremities. 

Peromelia — severe deformity of the extremities. 

Micromelia — small extremities. 

Perodactylia — small fingers or toes; often combined with bony 
syndactylia. 

Brachydactylia — shortening of the entire hand. Brachyphalangia 
— shortening of all or of a single finger. 

Ectrodactylia — absence of a single finger. Adactyliu — absence of 
all the fingers. 

Congenital Defects of Single Bones — Defect of the Upper 
Arm. — Isolated absence of the upper arm has not been observed. On 
the other hand, it is often underdeveloped when the forearm and hand 
are developed normallj^ and when the entire limb is defective in size. 
With the help of prosthesis defects of this sort may be made to 
functionate to an astonishing extent. 



1346 



THE SURGERY OF DEFORMITIES 



Defect of the Radius. — The radius may be absent from one or both 
forearms; the former is most frequently the case (Antonelli-). It is 
probable that a small portion of radius is always present. This is 
demonstrable in the Rontgeuogram. As a rule, the entire extremity 
is more or less atrophic. In most instances club hand {nianus vara) 
is present. 

Efforts at correction made early in life are followed by improvement. 
In some instances a certain degree of correction 
occurs spontaneously ; in others, the deformation 
of the hand increases. The latter may be ob- 
A'iated by redressment of the curved ulna and by 
mechanotherapy. After redressment correc- 
tional apparatus of celluloid or leather should be 
worn for several weeks. In adult life the manus 
vara may also be corrected by iilnar redressment, 
or b}- idnar linear osteotomy. The latter is 
preferable. 

Bardenheuer^ splits the distal end of the ulna 
and implants the carpus into the fork thus 
formed, so that the medial side of the splinter 
rests against the radial side of the carpus and 
vice versa. Both lower splinters are nailed to 
the carpus. The procedure corrects the deform- 
ity and is followed by improvement of function. 
Methods of this sort (osteoplasty) are preferable 
to resection of the carpus. 

Antonelli- employs a somewhat similar, though 
more complicated, method (see bibliography). 

The work of Albee* suggests the possibility of 
implanting a free lone cjraft obtained from the ^ig.^^ ^ p:"^!:^'' Ab- 
tibia in cases of this sort. sence of Femxjr. 

Ulxar Defect. — This is not so frequent as 
the absence of the radius and is usually complicated by defective 
musculature. The diagnosis is made certain by the Rontgenographic 
negative. Especial methods of treatment are not available. However, 
those applicable to the radius may be employed. 

Defective Femur. — As a rule, imperfect development of the long 
tubular bones of the extremities is attended with malformations of 
other portions of the body. Very often the corresponding lower leg is 
lijT)oplastic or deformed. The patella is ahsent in all cases, and asjon- 




DEFORMITIES AND ISOFTENlxXG OF BOXES 1347 



mt'try of the pelvic bones, the thorax, and the vertebral column are 
i"re(iuent coexisting conditions. Complete absence of the femur is 
rare; as a rule, a sector of bone is present at the upper end of the tibia. 
In cases of this sort the art of the orthopedic technician is of great 
assistance. The prosthesis shown in Figure 647 is simple and very 
satisfactory'. It is shown here in connection with the same case repre- 
sented in Figure 646. Fortunately the child 
was not afflicted with an additional malforma- 
tion. 

The role that developmental defects of the 
femur play in coxa vara is empliasized by 
Drehmann,'^ who regards the separation of the 
upper epiphysis, and consequent arrest of its 
growth, as responsible for a certain number of 
these cases. 

Tibial Defects. — One or both tibias may be 
absent, the latter case being the more frequent. 
The patella is ver}^ often absent. As a rule, 
complete or partial absence of the tibia is com- 
plicated by grave contractures of the muscles 
of the leg and deformity of the foot. Albert 
and V. Bramann" implanted the upper end of 
the fibula into the lower end of the femur, a 
measure which greatly increased the stability 
of the limb. Huntington^ implanted the upper 
end of the fibula into the upper stump of a 
partially defective tibia with a brilliant result. 
Stone^ repeated this with an equally satisfac- 
tory outcome. The contractures are treated by 
stretching. In this situation the employment of 
prosthesis is particularly useful. 

Fibular Defects. — These may be single or 
double. The tibia is shortened and bent with its concaAdty backward 
and toward the fibula. The foot is forced into the valgus or varus 
position ; occasionally, the tibia remains straight. 

The treatment in these cases is similar to that discussed in connec- 
tion with the tibia, and comprises the emplo^Tnent of redressment, 
mechanotherapj^ massage, gjTnnastics, pla.stic lengthening of tendons, 
osteotomy, and osteoplastic measures of relief. 

Forked Hand and Cloven Foot. — Partial or complete absence of a 




Fig. 647. — Prosthe- 
sis Applied to Case 
Shown in Figure 
646. 



1348 



THE SURGERY OF DEFORMITIES 



single (usually the middle) or of several metacarpal or metatarsal 
bones and their phalanges causes the hand or foot to be divided into 
two asymmetrical halves. 

The condition is frequently associated with syndactylia and may 
involve one, two, or all of the extremities. It is probably inherited, 
though some writers regard it, in some instances, as the outcome of 
strangulation by amniotic bands. 

Fission and Reduplication. — Fission defects are due to failure of 
coalescence of embryonic segments. This is not rare in connection 
with the spinal column, of which spina bifida is an example (p. 1422). 

Reduplication of a part 
(Supernumerary parts) is 
due to the division of a 
single embryonic anlage or 
to its separation by stran- 
gulation. The result is that 
there is a twofold develop- 
ment, one member of 
which, however, is rudi- 
mentary. 

Fusion Deformities. — 
Fusion occurs when the 
embryonic anlage of two 
organs or parts remain 
connected, though each de- 
velops separately. The 
phenomenon is attributed 
to hereditary variations 
and to mechanical interfer- Pig 
ence with development. 

The latter comes under consideration when other portions of the body 
present asymmetrical deformities. 

Symmelin is a term applied to complete or incomplete fusion or 
faulty separation of the lower extremities. It is also called "sii-en 
formation, ' ' a term which, considering its anatomical peculiarity, does 
not appear particularly appropriate. As a rule, it is attended with 
more or less arrest of development of the feet. 

Synosteosis, or coalescence of the bones of one or both forearms, is 
occasionallv met with. The condition has been studied by Biesalski,* 




648. — RONTGENOGEAM OP FOEKED HaND. 



DEFORMITIES AND SOFTENING OF BONES 1349 

Liebleiii/" and otliers. The M^ork of Riedinger^ may be consulted also 
to jid vantage. 

When the exact condition of affairs is revealed by the Rontgeno- 
grani, it is not infre<inently possible to establish a certain degree of 
function by means of osteotomy, redressment, and osteoplasty. 

Syndactylia. — Syndactylia is a congenital fusion of the fingers. 
It occurs in manifold forms and is often combined with other deforma- 
tions and with partial giantism (Fig. 649) or contractures. 

The mildest form is that of weh finger, in which the fingers are par- 





FiG. 649. — Syndactylia and Partial Giantism. 



tially or completely connected with one another. In severe cases the 
bones are united. 

Operative separation of the fingers is made difficult by insufficient 
skin. The principle underlying efforts of this sort is shown in figure 
650. Several additional methods of procedure are described by 
Jacobson and Steward. ^^ 

Malformations Due to Faulty Posture of the Fetus. — In this 
eategorj^ belong the malformations due to insuificient amniotic space, 
such as cluh foot and congenital luxations. However, most writers 
classify the former with developmental anomalies. 

Malformations Due to Excessive Development. — Malformations of this 
class are dependent upon intrinsic causes, i. e., an increase in the quan- 



1350 



THE SURGERY OF DEFORMITIES 



tity of aiilage material (hypertrophy) o.r of developmental energy 
(hyperplasia). "When abnormal growth involves the entire body, the 
term genuine giardism is used ; when it is restricted to certain areas, 
the term ■partial giajitism is employed. Leantiasis ossea, congenital 
elephantiasis of the shin, and macrodactylia belong to the latter class. 
In some instances, the process appears in the form of multiple 
exostoses. 

Giantism (Macrosomia). — In genuine giantism the entire body is 
symmetrically enlarged, as a rule, from the time of hirth, but the 
condition may develop later in life, i. e., about puberty. Cases not 
ascribable to congenital causes are not properly regarded as genuine 
instances of giantism (Sehwalbe^-). Most persons afflicted with giant- 
ism possess lovv-ercd resistance to disease and are easily fatigued. Ac- 
cording to Riedinger,^ 
this suggests disturb- 
secretions, which is 
illustrated by the fact 
that early castration 
is followed by abnor- 
mal growth of the 
bones. 

The manifestations 
of giantism may be 
limited to one side of 
anoes of internal 

the body, or to the lower extremities, or even to a single finger or toe 
(macrodactylia) . 

Acromegalia and le^ntia^is ossea are discussed in connection with 
hypertrophy of bones (Part V, chap. viii). 

PoLYDACTYLiA. — Hypcrdactylia may be single or double. As a rule, 
the increase is limited to a single phalanx, although at times two addi- 
tional phalanges are present (JoachimsthaP^). The adventitious 
phalanx is often very rudimentary (Fig. 651). It is generally 
amputated with ease. 

Developmental Disturbances of Bones. — Fetal diseases of bones occur 
as soon as the ovum has reached a certain stage of development. The 
skeletal diseases of the fetus do not differ from those of postuterine 
life. They are, however, more likelj^ to be attended with grave mal- 
formations when they occur during intra-uterine life. 

The Congenital Systemic Diseases of the Skeleton. — To these 





Fig. 



650. — Agnew 's Operation for Webbed 
Fingers. 



DEFORMITIES AND SOFTENING OF BONES i:]51 



belong chondrod ystrophia fetalis, osteogenesis imperfecta, athyreosis 
congenita {congenital myxedema), osteochondritis syphilitica, and the 
multiple cartilaginous exostoses and cnchondromata. 

Chondrod ystrophia fetalis is reallj' a fetal rachitis. It does not 
differ materially from that described in connection with diseases of 
bones (Part V, chap. viii). The fetal form of the disease is extensively 
discussed by Frangenheim" and by Siegert,^' who furnish complete 
bibliographies on the subject. 

Osteogenesis imperfecta consists in congenital incomplete ossification 




Fig. 651. — Poltdacttlism. 
(Symmers, Bellevue Hosj^ital case). 

of the hones, or in a meager formation of osteohlasts of the medullary 
substance and the periosteum. The bones remain thin and soft, or are 
brittle and porous (fragilitas osseum and osteopsathyrosis congenita) . 
As a rule, death occurs in utero or soon after birth. 

Athyreosis congenita (congenital myxedema) represents a disturb- 
ance due to a congenital defect of the thyroid gland. It is not related 
to the myxedema of adult life. It is often associated with congenital 
cretinism. The clinical picture is Yerj similar to the latter — apa- 
thetic f acies, stupid expression, large tongue, hoarse voice, low tempera- 
ture and dry skin. After a time the skin evinces the characteristics 



1352 THE SURGERY OF DEFORMITIES 

of a genuine myxedema. The pathological picture is that of arrest of 
bony development. 

Mongolism is a condition of congenital idiocy in wliich the features 
bear some resemblance to those of the Mongolian race. In addition to ' 
various malformations (hypoplasia), the joints are lax and the skin is 
mj'xedematous. The imbecility is likely to be " joyful " (merry 
imbecility). Its cause is unknown. 

Infantile myxedema begins about the fifth year of life (Siegert^^) 
and is due to a genuine hypothyroidism, the outcome of an acute 
infectious disease. It is attended with arrest of skeletal development. 
The disease is not well understood (see Frangenheim^^). 

Osteochondritis syphilitica, multiple cartilaginous exostoses and 
enchondromata, atrophy and hypertrophy of hones and softening of 
hones (rachitis and osteomalacia) are all responsible for a number of 
deformities. These are taken up in connection with Diseases of Bones 
(Part V, chap. viii). For detailed discussion, the authors mentioned 
at the end of the chapter (No. 16 to No. 21, inclusive) may be advan- 
tageously consulted. 

Of the chronic inflammatory processes involving the skeleton, tuber- 
culosis (Part II, chap, xxiii) is responsible for the greatest number of 
deformities, followed, in the order mentioned, by syphilis and chronic 
osteomyelitis. The same order is applicable to diseases of joints 
(Part V, chap, viii), especially in connection with anJcijlosis and 
arthrogenous contractures. 

In addition to this, deformities are the outcome of chronic inflam- 
matory diseases (of the same class) of muscles, tendons and bursae. 

The role that acute inflammatory processes of bones, joints and the 
soft parts play in the production of deformities is also taken up in 
connection with the discussion of diseases affecting those parts. How- 
ever, these are subjected to the same measures of relief addressed to 
the deformities due to chronic processes and, therefore, will not be 
given special consideration at this time. 

BIBLIOGRAPHY 

1. RiEDiNGER. In Lange's Lehrb. d. Orthop., Jena, 1914. 

2. Antoxelli. Zeitschr. f. orth. Chir., 1905, xiv. 

3. Bardenheuer. Same as Riedinger No. 1. 

4. Albee. Bone Graft Sure:., Phila. and London, 1915. 

5. Drehmann. Ergeb d. Chir. u. Orthop., 1903, xii. 

6. Albert und v. Bramann. See Riedinger No. 1. 

7. Huntington. Anns, of Surg., 1905, xli. 



DEFORMITIES AND SOFTENING OF BONES 1353 

8. Stoxe. Anns, of Surg., xlvi. 

9. BiESALSKi. Zeitschr. f. Orthop. Chir., xxv, 1910. 

10. LiEBLEiN. Zeitschr. f. Orthop. Chir., xxiv, 1909. 

11. Jacobson and Stewahu. Op. of Surg., i, Phila., 1902. 

12. ScHWALBE. Die Morpholoirie f. Malformationen, 1909. 

13. JoACHiMSTAHL. Ergiintz. a. d. Forschr. d. G-ebiet. d. Rontgenstrah, 

1909. 

14. Frangekheim. Ergeb. d. Cliir. u. Orthop., iv, 1912. 

15. Siegert. Ergeb. d. innern Med. u. Kinderheilk, viii, 1912, with com- 

plete lit. 

16. Ropke. Verh. d. Deutsch. Gesel, f. orth. Chir. »th. Kong., 1909. 

17. Zybell. Med. Klinik, 1910, with complete lit. 

18. V. Recklinghausex. Untersuch u. Rachitis u. Osteomalacia, Jena, 

1911. 

19. Wiexer. Arch. f. Orthop., xii, 1913. 

20. Fraexkel und Lovey. Ertriintz. d. Foi-schr. a. d. Gebiet. d. Rontgen, 

1910. 

21. DiESixG. Deutsch. med. Woch., 1913, No. 12. 



CHAPTER III 



CONGENITAL LUXATIONS AND CONTRACTURES 



Congenital Dislocation of the Hip. — Congenital dislocation of the hip 
was known to Hippocrates. About 1700 Verduc studied the problem 
on the cadaver with the view of developing a method of reduction. In 
1830 Humbert accomplished reposition on the living. Late in the 
nineteenth century, Roser and Reyher recommended and practiced 
excision of the head of the femur, and Paggi deepened the acetabulum 
after exposing it. Soon after this Hoffa and Lorenz perfected the 
open operation. To the latter belongs the credit of placing bloodless 
reposition on a sound basis, 
as the outcome of what 
Gaugerle calls "the painful 
but therapeutic espionage of 
the Rontgenogram. " 
The etiologij of congenital 
luxation of the hip has been 
made the subject of numerous 
hypotheses. At present two 
are regarded as determining 
developmental anomalies, and 
mechanical factors, the latter 
occurring iii utcro (faulty 
position of the fetus). 

Displacement of the head of the bone is made possible by stretching 
of the capsule, which is, however, attended with important alteration 
of the skeleton and soft parts. 

The skeletal alterations may be studied in connection with the 
Rontgenogram, especially the stereoscopic negative. However, as in 
all Rontgenograph negatives, the interpretation is not alwaj's a simple 
matter. 

At first, according to Lange,^ the caput femoris (in most cases) is 
luxated upward. It may (according to Kolliker and Hoffa^) remain 

1354 




Fig. 



6.52. — ROntgenogram of Congenital 
Luxation of Hip. 



CONGENITAL LUXATIONS AND CONTRACTURES 1355 



iu this position {typus luxationis supracotaylaidca) . Usually, how- 
ever, under the influence of the weight of the limb and stretching of the 
capsule, it is converted into a posterior upward luxation {typus lux- 
ationis supracotyloidea ct iliaco). In the last stage the head of the 

bone rests directly behind the ilium 
{typus luxationis iliaca) (Fig. 652). 

The pelvis, as the result of the femoral 
luxation, is forced into an abnormal posi- 
tion {compensatory pelvic tilt). This is 
especially noticeable in double luxation 
(Fig. 653) . In addition to this, the pelvic 
hones and the femur undergo atrophic 
changes. 

The head of the luxated femur shows a 
distinct hypoplasia, the neck is affected in 
a similar manner, and the shaft also 
atrophies, but to a less degree. The hj^po- 
plasia of the caput progresses year after 
year and by the time adult life is reached, 
it may be quite flattened out, resembling a 
"buffer" on a railroad car (Fig. 654). 

In many cases the neck of the bone 
undergoes deformation. This takes a 
variety of forms, such as lending, twist- 
ing, flattening, shortejiing, etc. 

The changes in the pelvis are usually 
congenital and consist in hypoplasia of 
the upper portion of the acetabulum. The 
roof of the latter is not broad and exca- 
vated, but presents a steep obliquity, 
which very often produces an indenture 
mto the caput (the "glide furrow" of 
Ludloff^). The floor of the pan, on the 
other hand, is hypertrophied and is broader than that of the normal 
side. This condition of affairs produces a flattening of the acetabu- 
lum. The acetabulum is never absent (Hoffa*). As life progresses 
the changes increase, until ultimately little of the outline of the 
acetabulum is discernible. The anatomical peculiarities in this con- 
nection are clearly depicted in a series of illustrations in the work of 




Pig. 653.— Double Congeni- 
tal Luxation at Hips. 

Note marked lordosis and 
pelvic tilt. 



1356 



THE SURGERY OF DEFORMITIES 



G-augerle.^ At the situation where the luxated caput is fixed an adven- 
titious acetabulum is formed (Fig. 655) (see also Ludloff^). 

The changes in the soft parts consist, of necessity, in shortening of 
the capsule, and the muscles, in accord with their location, are either 
shortened or lengthened. In either event, they ultimately become 

atrophic. The condition of the soft 
parts greatly interferes with reposi- 
tion. 

The clinical picture of unilateral 
luxation at the hip varies somewhat 
from that of the bilateral lesion. 





B 

Fig. 654 A and B. — Buffer Deformities of Heads of Femurs After Pro- 
longed Luxation (Congenit^vl). 

The smaller the child, the less manifest are the tjT)ical symptoms. 
In nursing infants they frequently escape notice, but become more 
evident as the child begins to walk and the body sinks toward the 
affected side. Locomotion is characteristic and is not an ordinary 
limping gait, but may be characterized as "waddling" caused by 
the shortening of the limb and the movements of the luxated femur. 



CONGENITAL LUXATIONS AND CONTRACTURES 1357 



The shortening varies from one quarter to one half centimeter at 
first, gradually increasing to from four to eight centimetei's in a few 
3'ears. As this increases, the child attempts to compensate for it by 
tilting the pelvis and walking on its toes. An important symptom is 
the Trenddcnhurg phenomenon, i. c, when the child stands on the 
affected side, the sound buttock sinks down (Fig. 656A), and when it 

stands on the sound 
side, the affected limb 
is held rigidly per- 
pendicular (Fig. 
656B). 

As the outcome of 
the shortening, a 
static scoliosis, with 
the convexity toward 
the affected side is de- 
veloped. 

In the posterior 
t^'pe of luxation the 
normal resistance im- 
parted to the fingers 
by the head of the 
bone behind the 
femoral artery is 

Fig. 65.5.— On the Left, Adventitious Acetabulum, absent and a distinct 
Eloxgated into a Triangle; on the Eight, A Xor- , ,, . . -r 

MAL Pan. hollow IS present. In 

the anterior tj'pe the 
caput is more prominent than is normal. For the purpose of deter- 
mining the location of the trochanter, the Boser-Nelaton line (p. 625) 
is of service. The elevation of the trochanter corresponds, in a general 
way, to the degree of shortening of the limb. In the tests care must be 
taken to maintain the pelvis on its normal level. The abnormal motil- 
ity of the head of the femur and the increased rotary excursion of the 
trochanter are of diagnostic importance. 

The s)j)npfoms in bilateral luxations are the same as those of the 
unilateral — much exaggerated. The dominant symptom is lordosis 
in the lumbar region. The latter is caused by the marked anterior tilt 
of the pelvis, which is secondary to the malposition of the heads of 
the femurs. The lordosis disappears wdien the patient is seated. 
Locomotion is distinctly "waddling," not limping. 




1358 



THE SURGERY OF DEFORMITIES 



The prognosis, without treatment, is unfavorable. When an adven- 
titious acetabulum is formed near the ncjrmal site of the pan, locomo- 
tion, with the aid of an artfully constructed prosthesis, may be satis- 
faetor}'. Even in these cases more or less pain persists during life. 

The treatment is divided by Lorenz*' into radical and 'palliative. 
The former aims at complete restitution to the normal; the latter is 





A B 

Fig. 656. — Teendelenbueg Phenomenon in Congenital Luxation of Hip. 
On the left the gluteal musculature is unable to hold the pelvis level. 

directed toward elimination of pain, contractural deformity, and 
limping. 

The Radical Treatment. — Bloodless reposition by the Lorenz 
method is carried out by the lever maneuver. Reposition is accom- 
plished over the posterior rim of the acetubulum. 

The patient lies supine on a table with the legs hanging over its 
edge. An assistant fixes the pelvis with the sound limb in maximum 
flexion at the hip. The luxated limh is flexed sagittalhj, at the kip 



CONGENITAL LUXATIONS AND CONTRACTURES 1:359 



joint 90° , in the knee 30°. In this way the sliortcncd adductor, the 
muscles of the tuberosities and the iliopsoas are relaxed, and a sudden, 
sharp pull, in the direction of the long axis of the flexed thigh, brings 
the caput fcntoris close to the posterior rim of the acetabulum {first 
phase of reduction — flexion 90°). 

Next, the shortened muscles are stretched by carrj/ing the flexed 
thigh outward to 90° of abductimi, so that it lies parallel with the top 
of the table {second phase of the reposition — abduction 90°). 

With the hand of the operator, or a fist, or a wedge, placed beneath the 
trochanter to act as a fulcrum, the oilier hand makes firm gradualhj increas- 
ing pressure on the knee {toward the floor), thus forcing the head of the 
bone against the isthmus of the capsule, widening it, and at the same time 
lifting tlie head of the bone over the edge of the acetabulum. 

Hoffa' and Schanz'* use the pendulum method. Lange^ uses an 
extension method, employing a special table not unlike that of Hawley, 
and a lever for the purpose (see bibliography). 

Rctcnlion of the reposition is the most important part of the blood- 



Li: 
Pig. 657.- 




FouRTH Phase of Eeposition Maneuver in Congenital Luxation 
OF THE Hip (Lorenz Method) ("Whitman). 



less method of Lorenz, whose work in this connection is particularly 
praiseworthy. 

hi the primary dressing the thigh is maintained in 90° abduction 
ami 90° flexion. The knee is flexed at right angles to the thigh (Fig. 
658). 

The application of the ggpsum must be carefully carried out. The 
patient is placed on a pelvic support ; the bony prominences are lightly 
padded and the gypsum applied evenly and thickly. This is best 
extended over the areas shown in figure 658. At the end of five or 
six weeks the area of the apparatus may be reduced, as is shown by 
the black lines in figure 658. Attention to detail in the care of the 



1360 



THE SURGERY OF DEFORMITIES 



child, especially with regard to cleanliness, is important. The posture 
in bed should obviate deformation of the apparatus. At the end of 
from two to five months the primary dressing is removed and a second- 
ary apparatus is applied. If at this time the head of the bone has 
remained reduced and the joint evinces some rigidity, abduction is 




Fig. 658. — Fixation in the Lorenz Primary Position. 
For greater secuiity the knee on the affected side and the sound thigh are 
included in the gypsum. The dotted lines show the limits of the dressing employed 
by a number of orthopedists. 

lessened 40° and the limb is rotated inward. The secondary apparatus 
conforms to that outlined by the black lines in figure 658. It is true 
that not a few more or less ingenious apparatuses have been con- 
structed to replace the gypsum for the secondary dressing. However, 
ordinarily the latter is the most readily handled. Secondary immo- 
bilization is maintained for ten weeks or more. 



CONGENITAL LUXATIONS AND CONTRACTURES 1361 

The treatment follawiny removal of the gypsum dressing is based 
on what is accomplished during the period of retention. Lorenz® had 
hoped that locomotion in the corrected position would cause the head 
of the femur to deepen the acetabulum. Springer and Weber'-' have 
shown that during this period no considerable reformation of the 
acetabulum takes place, and the latter does not show marked alteration 
in this connection for from one to two 3'ears after the reposition. The 
edge of the acetabulum does not deei)en while the limb is held still. 
The gypsum treatment is simply attended hy shrinkage of the capsule 
(particularly the cap) and of the soft parts, which prevents reluxation. 

For these reasons, the after care is ver^- important. Sudden exten- 
sion of the leg is to be avoided. Loreuz** emphasizes the need of per- 




FiG. 659. — GYPSUii "XiGHT Shell" Used in the After Treatment of Con- 
genital Luxation of the Hip. 

mitting spontaneous correction of the position of the limb ; only in 
older children is carefully executed redressment and the use of passive 
correctional motion permissible. In infants the use of a gypsum 
"night shell," as shown in Figure 659, is advisable. Later, the use 
of suitable restraining apparatus is a wise measure. 

Bloody reposition is carried out along the lines indicated in connec- 
tion with arthroplasty in this situation (see p. 838 ; also bibliography). 

The palliative treatment consists in the application of apparatus 
which tends to prevent increase of the deformity. These are not par- 
ticularly successful, but are likely to lessen pain and make locomotion 
more certain. 

Congenital Luxation of the Knee Joint. — This is a rare condition due 



1362 THE SURGERY OF DEFORMITIES 

to mechanical causes in utero. As a rule, only a subluxation is pres- 
ent. The anterior is the most frequent. The luxation is attended 
with grave interference with function. 

In young children reposition hy manipulation (see Dislocation, Part 
IV, chap, iii) is readily accomplished. Later in life, division of ten- 
dons, forcible correction and arthroplasty (p. 838) become necessary. 

Congenital Luxations of the Shoulder, the Elbow and the Hand. — 
These are very rare. None of them presents problems other than those 
discussed in connection .with Dislocations generally (Part IV, chap, iii) 
and Operations on Joints (chap. vi). 

Coi^enital Contractures. — Congenital contractures per se, that is, 
those not dependent upon malformations of bones and joints, are very 
rare. In most of the reported cases, the authors regard the causation 
as attributable to errors in embryonic development. The fingers are 
most often affected. 

The treatment includes gradual stretching, mechanotherapy, and, in 
severe cases, tenotomy. 

BIBLIOGRAPHY 

1. Lange. Lehrb. d. Orthop., Jena, 1914. 

2. KoLLiKER and Hoppa. Quoted by Gaugerle in No. 1. 

3. LuDLOPP. Erg. d. Chir. u. Orthop., iii, Berlin, 1911. 

4. Hoppa. Verb. d. deutsch. Gesell. f. Chir., Berlin, 1890, xix. 

5. Gaugerle. In Lange No. 1. 

6. LORENZ. Zentrbl. f. Chir., Leipzig, 1895, xxii; Verb. d. deutseh. Gesell. 

f. Chir., Berlin, 1896, xxv; 28th Kongr. d. deutsch. Gesell. f. Chir., 
1899. 

7. Hoppa. See Gaugerle in Lange No. 1. 
B. ScHANZ. See Gaugerle in Lange No. 1. 

9. Springer and Weber. See Gaugerle in Lange No. 1. 



CHAPTER IV 

TORTICOLLIS 

This deformit}^ (perhaps better called caput ohstipum) consists in 
stiffness of the neck and malposition of the head. It is not only 
caused hij permanent changes in the soft parts and bones, but also by 
temporary unilateral muscle spasm (v. Alberle^). When shortening 
of the sternomastoid muscle causes the malposition, the head of the 
patient is inclined toward the affected side and the face is turned 
toward the healthy shoulder. In the other classes of cases the ab- 
normal position is not as typical and varies with the underlying patho- 
logical causation, so that bending, twisting, elevation and depression 
of the head may be presented. In addition to this, a certain number 
of cases are ascribable to nervous influences and are called ftmctional 
or nerv&us torticollis, in contradistinction to the others, which are 
designated as organic torticollis or caput ohstipum. 

The lesion may be divided into three kinds, torticollis developed 
before hirth, during birth, and after birth (v. Alberle^). 

Of those developed before and during birth, the former are the 
result of lack of room in the uterus, which causes (1) the head to be 
fixed in an abnormal position and subsequent contracture of the sterno- 
mastoid muscle; (2) faulty development in the embryonic anlage; or 
(3) congenital osseous changes in the cervical vertebrae. The last 
consists in (a) coalescence of the atlas with the occipital bone; (b) 
synostosis of the atlas with the epistropheus; (c) coalescence of sev- 
eral cervical vertebrae; (d) the presence of a cervical rib; (e) the 
presence of adventitious vertebrae in the cervical or dorsal regions. 
V. Alberle^"^ depicts some startling specimens of this class of cases 
(see bibliography). 

Those caused during birth are the result of trauma during delivery, 
especially during difficult births (breech presentation), in which the 
sternomastoid muscle is subjected to undue strain. The injury con- 
sists in either stretching or partial or complete rupture of the muscle. 
In the newly bom the site of trauma is characterized by swelling and 

1363 



1364 



THE SURGERY OF DEFORMITIES 



pain involving the injured muscle. In man}- cases, spontaneous heal- 
ing without deformation occurs ; in others, more or less clearly defined 
torticollis follows. In the latter instance, the process takes on the 
form of a chronic myositis fibrosa (Pincus,^ Kader*). 

Of the symptoms, that of contracture of the sternomastaid muscle 
on the affected side is the most striking. The muscle stands out in 
a hard, short cord, especially when an effort is made to correct the 
deformity. In this way the 
head is inclined toward the 
side of the contracted muscle 
and turned toward the oppo- 
site .shoulder ; the ear is ro- 
tated forward ; the chin is 
somewhat lowered (Fig. 660). 
In severe eases, the head in 
toto is pushed toward the 
sound side. Voluntary motion 
of the head is considerably 
restricted. Viewed from be- 
hind, patients with torticollis 
present the picture of scoliosis. 

The .secondary change con- 
sists in : 

(1) Development of dorsal 
and lumbar scoliosis. 

(2) Asymmetrical develop- 
ment of the cranium and face. 

(3) Restriction of the 
visual field. 

The treatment during the 
first six months of life con- 
sists in redressment into over- 
correction and retention in 
the latter position. For the purpose of retention, a gypsum dressing 
(Lorenz^), or the reinforced celluloid wire apparatus of Lange* 
(p. 1338), may be used. In severe cases, operative methods of relief 
are necessary. 

Open tenotomy is practiced by many surgeons. It is objectionable 
because of the scar it leaves ; on the other hand, it has the advantage 
of being without danger. 




Fig. 660. — Left Sn)ED Torticollis. 

The clavicular portion of the sterno- 
mastoid muscle is strongly contracted. 



TORTICOLLIS 



1365 



Preliminary tenotomy at the lower end of the sternomastoid muscle, fol- 
lowed by addressinent of the vertebral column, is the method of choice. 

The tenotomy is performed as follows : The shoulder is elevated and 
the head is held over the edge of the table by an assistant, thus making 
the muscle prominent and tense. The tenotome is introduced — flat 
— between the two portions of the muscle about 1 cm. above its inser- 
tion and is advanced to the middle of the epistcrnal notch; the teno- 
tome is then turned toward the muscle fibers and these are divided 




Fig. 661. — Gypsum Dressing for Maximum 
Overcorrection of Torticollis (right side). 



with a stroking motion. Division of the fibers is attended with a 
decided jar. The tenotome is then turned toward the clavicular por- 
tion of the muscle and these fibers sectioned in a similar manner. 
The small stab w^ound is sealed with collodion. The object of the 
maneuver is to section the anterior fibers of the muscle while the 
posterior are torn by the traction made on the head. 

The tenotomy is followed by gradual modeling redressment of the 
cervical vertebrae until the scoliosis in this situation is over corrected. 
The correction is established when the ear on the sound side can be 



1366 



THE SURGERY OF DEFORMITIES 



brought in contact with the shoulder of the same side. In severe 
cases It may be necessary to expose the muscle and lengthen it by 
Z-shaped myoplasty. 

Retention of the overcorrected position is accomplished by the 
application of a padded gypsum dressing, such as is shown in figure 
661, in which the patient remains 
encased for about ten weeks 
(Lorenz"). 

The after treatmerit consists 
in correctional mechanotherapy, 
massage, etc. Lorenz swings his 
patients in a sling (Fig. 716) 
three times a day and has them 
wear a "diadem" (Fig. 662) at 
night for months. 

Torticollis Developing After 
Birth. — This is comparatively 
rare and is classified according to 
its cause. 

1. Cicatricial torticollis fol- 
lows deep burns and severe in- 
juries with loss of substance. It 
must be corrected hy plastic opera- 
tive methods of relief. 

2. H ahitual torticollis is 
usually occupational in origin, 
but may be due to errors of vision. 
The former is corrected by gym- 
nastics ; the latter, by the ophthal- 
mologist. 

3. Rheumatic torticollis is a 
transient affair and soon disap- 
pears under medication and the 
use of dry heat. 

4. Torlicollis after infections diseases follows scarlatina, measles, 
and diphtheria, and occurs in the course of lues. It is really a mj^osi- 
tis and usually disappears spontaneously. 

5. T^orticollis occurs in connection with diseases of the vertehral 
column {spondylitis), in spastic paralysis and in cerelral paralysis. 




Fig. 662. — ' ' Diadem ' ' for the After 
Treatment Following Correction 
OF Torticollis (left side). 



TORTICOLLIS 1367 

BIBLIOGRAPHY 

1. V. Alberle. Verh. d. Ges. Deutach. Naturfoi'scli, u. iirtz, Vienna, 1913. 

2. V. Albeule. In Lange's Lelirb. d. Ortliup., Jena, 1914. 

3. Pi NOUS. ZeitscJir. f. Geburtsh. u. Gyn., xxxi. 

4. Kadek. Beitr. z. klin. Chir., xvii-xviii. 

5. LoKENZ. Wien. mod. Wocli., No. 2 and No. 3. 

6. Lange. (With Spitz) Ilandb. d. kinderheilkunde, 1910. 



CHAPTER Y 
KYPHOTIC ANOMALIES OF POSTURE 

This subject opens a vista of far greater range than can be visual- 
ized within the horizon of this book. However, it is hoped that the 
following will indicate to the student the possibilities in this connec-. 
tion and induce him, as he progresses in his work, to give due attention 
to this subject (see bibliography). 

Kyphosis. — Kyphosis may be divided on an etiological basis : 

Congenital Kyppiosis. — Congenital kyphosis is very likely to be 
located in the upper segments of the spme. It is the result of embry- 
onic anomalies and of faulty position of the fetus; the latter may be 
due to amniotic bands (Dieulafe et Gilles,^ Gebhard-). 

Degenerative Curved Back. — Degenerative curved back has much 
in common with congenital curvature, is usually located in the upper 
segments of the spine, and frequently is associated with underdevelop- 
ment of the hodij and the mind (speech). The condition is regarded 
as heredilary and even racial (Jewish race). Hoffa^ thinks that it 
may be due to faulty innervation of the erector muscles of the back. 

Rachitic Curved Back.— Rachitic curved back is explained as fol- 
lows: When a child less than one year of age, with a feeble erector 
trunci, is allowed to sit up, it develops a kj^photic deformity at the 
junction of the thoracic and lumbar vertebrae (Fig. 663). If the 
child is rachitic, the k^'phos becomes a very distinct one. As a rule, 
both of these conditions disappear spontaneously. However, in not a 
few instances, the deformitj^ (more or less marked) is permanent. 
The earlier the child sits up, the lower down is the kyphos. 

Relaxation Round Back. — Relaxation round back occurs at the 
age of the greatest elongation of the spine (nine to thirteen). Lange* 
calls this the round back of school children. No other causative factor 
need be taken into account, and, as Spitzy^ says, '' considering the prev- 
alent method of school training, it is astonishing that the condition 
is not more common.'' He regards the deformity as directly due to 
faulty posture of the child, though a feeble constitution is the indirect 
underhdng cause. The first indication of the deformity reveals the 
existence of the constitutional condition and demands that both be 

1368 



KYPHOTIC ANOMALIES OF POSTURE 



1369 



takeu iu hand at ouce. Spitzy" presents a striking word picture of the 
process from its inception to the final, permanent deformity (see bib- 
liography). This condition of affairs can be found by any general 
practitioner who will make the study of the welfare of his young 
patients the object of proper observation. The avoidance of this con- 
dition will save much recrimination (child to mother), many tears, 
and great unhappiness. 

Occupational Round Back. — Occupatiomal round back is de- 
termined by the overdevelopment of the flexors of the spine as com- 
pared to the erectors. It is 
usually located in the thoracic 
vertebrae, though the other sec- 
tors of the spine may be the seat 
of the curve. 

The Round Back of Old 
Age. — The round back of old 
age is a reversion to the muscu- 
lar feebleness of early childhood, 
influenced to a certain extent by 
the ankylosing effect of chronic 
arthritis. 

The diagnosis of round back 
does not present any difficulty, 
except, perhaps, in children in 
whom differentiation hetiveen 
rachitic kyphosis and spondylitis 
must he made. The former is 
inflii€7iced iy posture, the latter 
is not. 

The prognosis is favorable in 
all but degenerative and the fixed rachitis forms of the deformity'. 
The treatment relates primarily to prophylaxis. This is essen- 
tially the dut}' of the general practitioner, who should instruct the 
parents to see that assumption of the erect posture is discouraged, 
that crawling is encouraged, and that hreathing exercises and gym- 
nastics in the open air are diligently and intelligently executed. It 
is important that exhausting procedures (especially the cold bath, an 
idiotic practice of modem times) be avoided. The attire of the child 
should receive careful attention and it should be encouraged to lie 
on its abdomen. The beginning of school life should be postponed 
and under no circumstances should a child with a " weak back " be 




Fig. 663. — Severe Form of Eachitic 
' ' Sit Ktphos. ' ' 

Apex at dorsolumbar junction. 



1370 



THE SURGERY OF DEFORMITIES 



forced to sit at the piano or at " lap work ' ' for protracted periods of 
time. Massage of the back is of great serv-ice. Later in life the use 
of gymnastics is perhaps the most helpful measure of relief. 

In the employment of gymnastics 
the character of the exercises suitable 
to the given problem must be care- 
fully selected. This is a subject of 
considerable magnitude, to which the 
student will find special works de- 
voted. That of Whitman® is valuable. 

Scoliosis — Lateral Curvature of the 
Spine. — In a general way, scoliosis 
consists in lateral deviation of the 
vertebral bodies. However, this is, of 
necessity, combined with modification 
of the normal curves of the spine, so 
that a pure frontal deformation is 
rarely observed, except, perhaps, in 
the form of an absence of physiologi- 
cal curves, as in "flat back." 

The causation of scoliosis and the 
mechanism of its development are 
divided as follows: 

CoNGENiT^VL. SCOLIOSIS. — Congenital 
scoliosis is due to asymmetrical de- 
velopment of the bones of the spine 
and, especially, to the presence of a 
supernumerary vertebral body, both 
of which cause the spine to curve. In 
the latter instance, the convexity of 
the curve faces the side where the 
adventitious bone is located (Putti,'^ 
Garre,^ Drehmann,® Bohm^*'). It is 
also caused by the influence of skeletal 
anomalies of parts connected with the 
vertebrae, such as "high shoulder" (cervical rib), defects of the 
pelvis, etc. (Garre,* Drehmann^). Naturally', congenital scoliosis is 
attended with additional deformations of the trunk and pelvis, the 
outcome of compensatory postural efforts, and, ultimately, the de- 
formity of the spine becomes fixed and irremediable. 




Fig. 664. — Left Sided Lumbo- 
DORSAL Scoliosis. 

Apex of the bow in the region 
of the ninth dorsal vertebra. 
Rigidity from the seventh to 
the eleventh dorsal vertebra; 
overhanging trunk ; great tor- 
sion ; rib hump on the left ; con- 
cavity on the right side. 



KYPHOTIC ANOMALIES OF POSTURE 1371 

Racttitic Scoliosis. — Rachitic scoliosis (Fig. 664) probably repre- 
sents most of the severe form,s of this class of deformities. It bej^ins at 
about the time the child assumes the erect position and influences the 
entii-e confoi'mation of its body. As already stated, postural kyphos 
is often associated with lateral curvature. The apex of the rachitic 
lateral curve usually corresponds to the dorsolumbar region. The 

LATER IN LIFE THE LATERAL CURVATURE DEVELOPS, THE MORE LIKELY IS 
ITS APEX TO CORRESPOND TO A VERTEBRA AT THE CENTER OF THE DORSAL 

REGION. In childhood the soft bodies of the vertebrae readily conform 
to the weight of the erect body. The changes in the vertebrae coin- 
cident with rachitic scoliosis are the same as those occurring in the 
rachitic form of rigid "round back." Rachitis, of itself, merely 
softens the bon*es and weakens the ligaments of the spine. Indeed, 
severe rachitis may occur and the back remain perfectly normal in 
outline. It must be remembered that, given the presence of rachitis, 
scoliosis develops as the result of error in the care of the child 
(Spitzy^). 

Habitual Scoliosis. — Habitual scoliosis corresponds to relaxation 
' ' round back, ' ' and, as in the latter, its causes are postural. 

Paralytic Scoliosis. — Paralytic scoliosis occurs in connection with 
hemiplegia, with weakness of the musculature of the spinal column 
on one side and overactivity on the other. 

Static Scoliosis. — Static scoliosis develops in connection with 
shortening of a lower limb (compensatory scoliosis). A curvature of 
this sort rnaij hccome fixed when it exists for a long time and it is not 
aholished hij the position the patient assumes during rest. 

Cicatricial Scoliosis. — Cicatricial scolioses are due to adhesions of 
scar formation (bands) in connection with suppurative processes 
within the thorax. To these may be added the so-called respiratory 
curvatures due to irregular action of the diaphragm, in which one 
side contracts more than the other as the result of pulmonary con- 
ditions. This is of course most likely to be the case in rachitic 
children. 

Scoliosis may he due to persistent pain (ischiatic nerve, kidney, 
lumbago). This is really a postural deformity, the patient assuming 
an abnormal position in an effort to relieve the pain. Its permanency 
is dependent upon the persistence of the pain which, in turn, depends 
upon the underlying cause. 

Hysterical scoliosis is associated with lowering of the motor inner- 



1372 



THE SURGERY OF DEFORMITIES 



vatiou of certain groups of rauscles. It is very likely to be transient 
or intermittent and rarely results in fixation of the deformity. 

In all cases of scoliosis the underlying cause must be discovered, if 
possible. Its removal is not rarely followed by spontaneous disap- 
pearance of the deformity (Spitzy'). 

Xo problem in surgery has been made the object of greater care 
and (the word is used advisedly) devotion than that of the patho- 
logical anatomy of scoliosis. It 
is to be regretted that lack of 
space does not permit inclusion 
of details here. 

Lateral curvature of the spine 
is always attended with rotation 
(torsion) . The greatest rotation 





A B 

Fig. 665. — Skeletal Preparation. 
A, Severe left sided scoliosis. B. The same from above (Lange). 



occurs when the thoracic spine becomes kyphotic. The greater the 
relaxation, the greater the curve in the spine and the greater the 
increase in deformity caused by the lever action of the ribs as these 
become separated from one another. The influence of rotation upon 
the form of growing vertebral bodies is easy to understand. Their 
growth and conformation respond to rotation in the same manner as 
the spiral action of the arm is developed in the human to conform to 
the erect position. In the upper portions of the bodies of the vertebrae 
the bonv canals are twisted in the direction of the rotation. This 



KYPHOTIC ANOMALIES OF POSTURE 



1373 



torsion and its attendant changes of necessity affect all the bony parts 
connected with the vertebral column. 

The spinous processes incline toward the side of the convexity. In 
severe scoliotic deformities a number of combinations of curves occur 
and the spine winds in and out in lateral deviation, torsion, back- 
ward inclination, and kyphotic and lordotic bowing. 

The bodies of the vertebrae are deformed in accord with the position 
thej' occupy in the scoliotic arc, the one at its apex, like the keystone, 
being wedge shaped, the obliquity of the other bones diminishing as 
the terminations of the curvature on either end are reached. At the 




Fig. 666. 



- The XrvELLiER Trapeze of Schulthess, to Determine the Degree 
OF Difference in the Xiveau of the Thoracic Skeleton. 



outer margin of the wedge the bone tissue is loose and the canals are 
enlarged (from hydraulic medullary pressure, Nikoladoni"). The 
changes in the vertebrae also greatly interfere with the motility of 
the individual vertebra and the spine as a whole. 

The ribs undergo a characteristic scoliotic deformity, which is re- 
sponsible for the most dominant deformation of the trunk as a whole. 
The torsion of the spine causes the ribs on one side to protrude progres- 
sively; on the other (the concave side), they become more or less 
flattened. This deformity exercises an unfavorable influence on respi- 
ration, an important factor when the affliction is complicated with 



1374 



THE SURGERY OF DEFORMITIES 



lung tuberculosis. The gradual approximation of the ribs, especially 
in advanced life, causes pressure on the intercostal nerves and gives 
rise to severe neuralgia. 

The pelvis is influenced because of its relatively rigid connection 
with the sacrum, which follows the movements of the spine. The 
diameter of the pelvic cavity is often seriously impaired because of 
inherent deformations of the pelvic 
bones and as the result of the encroach- 
ment of the distorted spinal column. 

The clinical picture of scoliosis varies 
with the form of the curvature. In 
estimating these deformations, those 
that are the outcome of faulty posture 
must be excluded. Thc}^ are differ- 
entiated by the fact that the deformity 
is not maintained when the patient 
assumes the position of rest. 

All other forms of scoliosis hegin 
with lateral curvature of the spine in 
the "rest posture," From here to fix- 
ation is not a long step. Fixation is an 
important determining factor in decid- 
ing the presence of scoliosis and is 
indicated by modification in the range 
of the spine. Movements to the right 
or left are not accomplished to the 
normal degree nor are they symmetri- 
cally executed. "The alignment of the 
spinous processes does not follow the 
motions of the trunk, but shows irregu- 
larities in sequence" (Lange*). Loss 
of function is soon followed by persist- 
ence of the deformity when weight hearing is absent. About this time, 
symptoms of torsion appear and the case soon assumes the type of 
deformit}' wnth which we are, unfortunately, so familiar (Figs. 664 
and 665). 

The coincident deformities consist in elevation of the shoulder and 
hip. Locomotion is attended with limping. The head is usualh' car- 
ried to one side. 

The examination and establishment of the diagnosis are especially 




Fig. 667. — Determining the 
Position of the Pelvis in 
Scoliotic Deformity by 
Means of the Nivellier 
Circle of Schulthess. 



KYPHOTIC ANOMALIES OP POSTURE 



1375 



important. Early recognition of the affliction is of inestimable value 
with regard to treatment and may be considered as determining the 
l)rognosis. 

The upper body must he exposed to the trochanters. The patient is 
instructed to walk a few steps in order to detect errors in gait. Next, 
the locations of the spinous processes are indicated with a skin pencil. 
Sudden disappearance of the processes indicates torsion. The degree 
of fixation is determined by observing the outline of the spine in the 
"rest posture." By drawing the shoulder blades forward, torsion and 
deformity of the thorax may he accentuated. The extent of thoracic 

deformity may be standardized 
by means of the nivellier tra- 
peze of Schulthess^^ (Fig. 666). 
The position of the pelvis may 
be determined accurately by a 
similar instrument, also de- 
vised by Schulthess^- (Fig. 
667). 

The prognosis in scoliotic 
processes depends upon their 
etiology. The congenital forms 
are the least likely to be im- 
proved. Those developed early 
in life and the paralytic forms 
also present an unfavorable 
condition of affairs with regard 
to ultimate outcome. 

Of the prophylaxis and treat- 
ment of scoliosis, the former has 
already been discussed in connection with "round back." In this 
connection the imperative necessity for strict observation of the pre- 
cautions mentioned is emphasized by the consideration that rachitic 
scoliosis is attended with changes in the bone which, when once estab- 
lished, are not readily influenced even by the greatest care and skill 
in treatment. 

Passive correction and overcorrection are accomplished in the 
simplest manner by suspension (Fig. 716), which should lift the patient 
from the floor so that contact with the latter is barely maintained with 
the toes. This determines the degree of fixation w^hich is not being 
overcome by the maneuver. The use of the sling with the patient lying 




Fig. 668.— Lange's Correctional Pos- 
ture Apparatus for the Treatment 
OP Scoliosis. 
The traction of the belt overcorreets 

the deformity. 



1376 



THE SURGERY OF DEFORMITIES 



down is less forcible in its effect. This merges into the widely used 
correctional '^ posture apparatus," of which that of Lange^^ (Fig. 668) 
is the simplest. The patient occupies this position for certain periods 
only of the day. The best results are obtained in cases in which 
fixation has not yet occurred. The construction of ambulatory appa- 
ratus is of course simply a matter of mechanics. One form is shown in 
figure 669. However, 
this, like all immobiliza- 
tion apparatus, is objec- 
tionable, on the ground 
that weakened muscula- 
ture is encouraged in its 
inactivity. Apparatus of 
this sort should be used 
only in connection with 
correctional gymnastics, 
massage, mechanotherapy, 
etc. 

When fixation of the 
deformed spine has oc- 
curred, the problem is 
amplified. Efforts at its 
solution have occupied 
the attention of ortho- 
pedists for years. Among 
the publications devoted 
to the subject those of 
Schulthess," Lovett,^^ 
Spitzy,"Roth," Schanz,^^ 
and Abbott^^ may be 
studied to advantage. 

The work of the last of 
these (Abbott^^) has at- 
tracted wide attention. 

Spitzy,^ whose work in this connection extends over a lifetime, says 
''The latest step (in correction of scoliotic deformities) has been 
taken by Abbott, who encases his patients (in gypsum) while in the 
kyphotic position, on the assumption (which is, according to my ex- 
perience, a correct one) that this corresponds to the intermediate posi- 
tion of the spine, in which the ligaments are the most elastic and cor- 




FiG. 669. — Eedressment Apparatus fob Am- 
bulatory Correction of Scoliosis (Lange). 



KYPHOTIC ANOMALIES OF POSTURE 



1377 



rectioii is most likel}- to bo attained." It is true that a few orthopedists 
are disinclined to employ prypsum apparatus in the treatment of scoli- 
osis (Lorniiz^'^) ; others (Schanz,'« Gauprerle,'^ Whitman") regard it 
as of great value. Spitzy'' uses the method only in severe cases, and 
in these insists that nothing is of greater service than the method 
as laid down by our own Abbott.^® 
For the purpose, the patient is postured as shown in figure 670. 

B}' means of this position 
and by traction with fabric 
bands the concave deform- 
ity is corrected as far as is 
possible, and the gj-psum is 
applied as described in 
connection with spondylitis 
(p. 1439) . A window is cut 
in the cast over the old pro- 
trusion (Fig. 671), and 
through this are inserted 
felt pads which, as time 
progresses, may be in- 
creased in thickness. The 
apparatus is changed every 
four or six weeks. 

Of the operative meas- 
ures of relief in scoliosis, 
that of Albee,-^ though of 
recent origin, seems to pos- 
sess certain possibilities. 
The technic of the pro- 
cedure is as follows : 

A gypsum bed with firm 
lateral walls should be 
molded, before the opera- 
tion, to the back and sides of the patient's trunk and allowed to 
harden in the corrected position. Six to eight transverse processes 
at the apex of the scoliotic curve are exposed by the incision used in 
spondylitis (p. 1443). The muscles and ligaments over the tips 
and between the transverse processes are split in approximately 
equal halves with a scalpel. The transverse processes are split longi- 
tudinally, into halves, of which the posterior is set over to make room 




Fig. fi70. — Posture of a Left Sided Lum- 
BODORSAL Scoliosis in Maximal Flexion 
AND Consequent Eelaxation of the 
Spine (Abbott). 

The patient rests on a canvas hammock, 
which is "slack" on tlie right side so as to 
permit of protrusion of the body on that 
side and to attain ' ' overcorrectional tor- 
sion." The gypsum is applied in this posi- 
tion. 



1378 



THE SURGERY OF DEFORMITIES 



for the graft. Determination of the graft, the manner of obtaining it, 
and the means used to place it in situ are the same as those described 
in connection with spondylitis (p. 1443). While the patient is held in 
the corrected position, the ligaments and muscles are drawn over the 
site of repair with kangaroo tendon. 

The wound is closed with silkworm 
gut and, after the protective dressing 
is applied, the patient is bandaged 
into the previously prepared gj'psum 
bed. At the end of six weeks, a well 
molded gypsum case is worn for from 
ten to' twelve weeks. After the post- 
operative period is over, correctional 
gymnastics, etc., may be employed. 

Deformities of the Thorax. — A num- 
ber of these are the result of develop- 
mental anomalies. Deformations of 
this sort interfere more or less with 
freedom of respiratory movements of 
the thorax and are not infrequently 
found in persons afflicted with lung 
tuberculosis. 

Chicken Breast. — In chicken 

Fig. 671. — Eight Sided Thor- 
acic Scoliosis in "Overcor- 
rection" Gypsum Appara- 
tus. 

Contratorsion is prevented by 
the introduction of felt pads 
through the window. 



breast (pectus carinatum) the 
thorax appears narrowed in 
its transverse diameter, so 
that the sternum protrudes 
beyond the level of the ribs. 
A depression is visible on 
either side of the sternum 
from the fourth to the eighth 
rib ; the lower edges of the 
ribs are everted. The condi- 





FiG 672. — BoxE Grapt in Tips of Lateral 
Processes of Convex Side of Corrected 
Paralytic Scoliosis (Albee). 



KYPHOTIC ANOMALIES OF POSTURE 1379 

tion is usually rouiul iu severe ronns of rachitis in inl'auts. It is 
frequently associated with rachitic kyphosis. As a rule, the deformity 
becomes less marked as life progresses. The treatment is similar to 
that of rachitis. 

Funnel Breast. — Funnel breast (pectus infundihuliforme) is the 
reverse of chicken breast, the sternum being located behind the level 
of the ribs. It is regarded as the outcome of developmental anomalies. 
Spitzy'' discusses its causation at some length. Lange* has succeeded in 
improving the condition by the use of suction, over the funnel by 
means of a glass bell, from which the air is exhausted with a hand 
pump. 

Cicatricial Deformities. — Cicatricial deformities of the thorax 
follow the shrinkage of the pleural cavity after mflammatory pro- 
cesses in this region. Much of this may be prevented by mechanical 
treatment of the causative process. 

Spondylitis is taken up in connection with Surgery of the Spine, 
Part IX, chap. iii. 

BIBLIOGRAPHY 

1. DiEULAFB ET GiLLES. Bull. et. mem, de la soc. de Paris, 1905, July. 

2. Gebhard. Arch. f. Ortliop., viii. 

3. HOFPA. Lehrb. d. Orthop. Chir., Stuttgart, 1902. 

4. Laxge und Spitzy. Chir. u. Orthop. dm Kindesalter, Leipzig, 1910. 

5. Spitzy. In Lang-e's Lehrb. d. Orthop. Chir., Jena, 1914. 

6. WiiiTMAX. Orthop. Surg., Phila. and N. Y., 1917. 

7. PuTTi. Zentrbl. f. Chir., ii, 1910. 

8. Garre. Zeitschr. f. Orthop. Chir., 1902, xi. 

9. Drehmann. Zeitschr. f. Chir., ii, 1911. 

10. BOHM. Verb. d. Deutsch. Gesell. f. Orthop. Chir. vi, Kong. 1907. 

11. NicoLADONi. Anat. u. Mechan. d. Skoliose, Vienna, 1909. 

12. Schulthess. Zeitschr. f. Chir., i. 1911. 

13. Lange. Munch, med. Woch., No. i, 1905. 

14. Schulthess. Jaochim's Handb. d. Orth. Chir., i. 

15. LovETT. Boston Med. and Surg. Jr. vi, 1900; Jr. of the Boston Soc. of 

Med. Sci., 1900, iv; Jr. A. M. A. xlvi, 1906; Boston Med. and Surg. 
Jr., cxiv. 

16. Spitzy. Zeitschr. f. Orthop. Chir., xiv. 

17. Roth. Brit. Med. Jr., 1912, Apl. 20. 

18. ScHANZ. V. Langenbeck's Arch. Ix. 

19. Abbott. N. Y. Med. Jr. April, 1912, xcv. 

20. LoRENZ. Same as Spitzy No. 5. 

21. Gaugerle. Same at Spitzy No. 5. 

22. Albee. Bone Graft Surgery, Phila. and London, 1915. 



CHAPTER VI 

DEFORMATIONS OF THE UPPER EXTREMITIES 

Congenital Elevation of the Shoulder. — Congenital elevation of the 
shoulder may be unilateral or bilateral. The condition was first de- 
scribed by McBurney and Sands^ (1888) and was worked out by 
SprengeP (1891). It is widely known as Sprengel's disease. In 
1908 Horwitz^ analyzed 136 cases collected from the literature. The 
lesion is characterized by deformation of the scapula and is regarded 
as the outcome of intra-uterine disturbances of development. Max 
Colm* reports a case in which unilateral elevation of the shoulder was 
caused by tension of the levator angulae scapulae, the latter being 
due to scoliosis coincident with the presence of an adventitious vertebra 
in the thoracic region (7th). 

The symptoms consist in an actual elevation of the deformed scapula. 
The scapula is rotated on its medial axis and its upper edge is luxated 
forward. The shoulder appears shortened and the entire scapula 
girdle droops forward and inward. The Rontgenogram reveals the 
deformation of the scapula, which presents exostoses and is frequently 
attended with a cervical rib and other bony anomalies. Congenital 
elevation of the shoulder is associated with scoliosis, the former being 
on the convex side of the latter. The deformity of the scapula inters 
feres mechanically with lifting the arm. 

Mechanotherapy, redressment, and apparatus do not improve the 
condition. Kolliker^ resects that portion of the scapula which inter- 
feres with motion of the arm. If cosmetic effect alone is to be con- 
sidered, section of the levator scapulae, supraspinatus, the anterior 
serratus and subscapularis muscles and subsequent fixation of the bone 
in the corrected position may be practiced. Spitzj^^ advises that a bony 
connection between the spine and the medial edge of the scapula be 
searched for in all cases. In some instances, an abnormally large cor- 
acoid process is responsible for deformity, this may be removed. 

Acquired Elevation of the Shoulder. — Acquired elevation of the 

1380 



DEFORMATIONS OF THE UPPER EXTREMITIES 1381 

shoulder may be reg-arded as an independent condition when it is not 
associated with doro-rmation of the spine. 

Its causaiioi is varied. In most in.stajices, the deformity is a part of 
a rachitic condition, but it is also ascribable to inflammatory shorten- 
ing of the muscles that lift the scapula and to an hysterical basis. 

The st/iiip(oins are similar to those of the congenital form and the 
treatment is the same. 

Scaphoid Scapula. — Scaphoid scapula is described by Graves' as a 
clinical entity ccmsisting- of deformation of the scapula itself (sca- 
phoid). The bone is very much elongated beyond the normal. The 
shoulder hangs forward and downward (winged scapula). Graves' 
regarded the condition as luetic in origin. However, subsequent in- 
vestigation seems to prove it developed in utero from faulty position 
or as the result of an embrj-^nic anomaly. 

Rheumatic Shoulder. — So-called rheumatism of the shoulder has 
been made the object of careful study, especially by Goldthwait.® 
There is, of course, such a thing as rheumatism of the shoulder, which 
presents the usual clinical picture of this disease. However, the class 
of cases referred to exhibits persistent pain without the other manifes- 
tations of rheumatism. 

According to Goldthwait,^ the condition is characterized by forward 
and downward sinking of the shoulder, in which the pain is due to 
two separate anatomical peculiarities. One consists in compression of 
the burea between the coracoid pix)cess and the minor tubercle of the 
humerus ; the other, in pressure on the nerves of the brachial plexus. 

In either event, relief is afforded by holding the shoulder in its 
normal position. This is accomplished by correctional gymnastics, 
though at times it becomes necessary to fix the arm for several weeks 
in the fully abducted position. 

Obstetrical Paralysis of the Arm. — Obstetrical paralysis of the arm 
usually occurs sequentially to difficult labor, though it may develop 
in a normal deliver^". 

Two causative factors enter into its development, injurj^ to the 
brachial plexus (Bieslaski^) with or without fracture of the humerus, 
and a genuine distortion (Lange^"). 

The symptoms, in recent cases, consist in limitation of the function 
of the joint ; later, atrophy, contractures, internal rotation of the arm, 
and drop wrist appear. The differential diagnosis is established by 
the electrical reaction. 

The treatment in fresh cases of distortion consists in fixation of the 



1382 



THE SURGERY OP DEFORMITIES 



arm in external rotation and abduction (90°) in a gypsum bed. 
Later, passive stretching of the capsule and active gymnastics are em- 
jjloyed. If these measures fail, forcible redressment under narcosis 
and immobilization in the corrected position for six weeks are em- 
ployed. This is followed by the use for six months of the gypsum 




Fig. 673. — Gypsum Bed for the Treatment of Distortion of the Shoulder in 

Infants. 



bed shown in figure 673. In children more than two years of age, 
redressment does not afford relief. In these cases osteotomy is neces- 
sary. 

For the purpose, an incision is made through the outer bicipital 
groove, the periosteum is elevated, and the bone is divided transversely. 



DEFORMATIONS OF THE UPPER EXTREMITIES 1383 

The lower fragment is rotated outward and the limb is fixed in 
this position in gypsum for six weeks. 

In genuine paralysis, neuroplasty is indicated. 

Spontaneous Subluxation of the Hand. — Spontaneous subluxation of 
the hand (Madelung's deformity, radius curvus, fork hand) is a lux- 
ation of the lower end of the radius with the carpus toward the 
palmar side, so that the lower end of the ulna stands out prominently 
in the dorsum of the forearm (Fig. 674). Gaugerle" attributes its 
occurrence to relaxation of the ligaments of the wrist joint. The 
condition is readily controlled by the prolonged employment of a 
suitably constructed celluloid or leather "restraining manchette." 




Fig. 674. — Madelung's Deformity (Whitman). 

Dupuytren's Contraction. — This is already discussed in connection 
with Diseases of Joints (Part V, chap. vii). 

Acquired Contractures. — Acquired contractures of fingers are taken 
up in Part IV, chap. ii. 

Kruckenberg's Finger Contracture. — Kruckenberg's^- finger contrac- 
ture occurs in connection wnth luxation of the flexor tendons. Kruck- 
enberg suggests that a groove be ciit in the bone -and the tendons placed 
in it. Spitzy^^ forms a flap from the fibrous covering of the metacarpo- 
phalangeal joint and turns it over the reduced tendons. He reports 
five cases successfully treated in this way. 

Tendon Sheath Stenosis. — Stenosing tendon sheath, inflammation at 
the styloid process of the radius is a lesion reported by De Quervain^* 
and by Paulsen^^ as a clinical entity. It appears to consist in a chronic 
inflammation of the ligamentum carpi which strangulates the ten- 
dons ; the latter are unchanged. Exposure by incision and division of 
the constricting bands is followed by prompt relief. 



1384 THE SURGERY OP DEFORMITIES 

BIBLIOGRAPHY 

1. McBuRNEY and Sands. Quoted by Rosenfeld iii Lange's Lehrb. d. 

Ortrop., Jena, 1914. 

2. Sprengel. Quoted by Rosenfeld in Lange's Lehrb. d. Orthop., Jena, 

1914. 

3. HoRWiTZ. Amer. Jr. Orthop. Surg., vi. 

4. Max Cohn. Zentrbl. f. Cliir., 1907. 

5. KoLLiKER. In Joachinthal's Handb. d. Orth. Chir., Jena, 1907. 

6. Spitzy. Same as No. 1. 

7. Graves. Jr. A. M. A., 1910, Iv. 

8. Goldtiiwait. Amer. Jr. Orthop. Surg., 1909. 

9. Bieslaski. Same as No. 1. 

10. Lange. Miineh. med. Woch., 1912, No. 2G. 

11. Gaugerle. Arch. f. klin. Chir., Bd. Lxxxviii. 

12. Kruckenberg. Jahrb. d. Hamb. Staatskrank, ii, 1890. 

13. Spitzy, Arch. d. Orthop., 1. 

14. De Quervain. See Miehaelis-Zeitschr. f. Orth. Chir., xxx. 

15. Paulsen. See Miehaelis-Zeitschr. f. Oi^th. Chir., xxx. 



CHAPTER VII 

DEFORMITIES OF THE LOWER EXTREMITIES 

COXA VARA 

Coxa vara is an anatomical characterization of a bending of the 
neck of the femur, which produces a distinct clinical picture in many 
cases. It was first described by Fiorani^ in 1882. The lesion may be 
divided as follows : 

I. Congenital coxa vara. 

II. Acquired coxa vara. 

1. Rachitic coxa vara. 

2. Static coxa vara. 

3. Traumatic coxa vara. 

4. Inflammatory coxa vara. 

5. Coxa A'ara from other causes. 

Congenital Coxa Vara. — This is attributed to intra-uterine pressure 
and to diseases developed during fetal life. 

The clinical picture of congenital coxa vara does not become manifest 
until the child begins to walk. It is usually attended with a club foot 
or ankylosis of the knee joint. Ahdiiction and flexion at the hip are 
restricted because the neck of the bone is already abducted when the 
limb is held parallel to the head and the under side of the capsule is 
shortened, and also because the tip of the trochanter impinges on the 
border of the acetabulum or the ilium. 

The diagnosis is made certain by the Rontgenogram. This is im- 
portant, as the condition is readily mistaken for congenital luxation at 
the hip joint. 

The treatment is taken up in connection with the acquired forms of 
coxa vara. 

Acquired Coxa Vara. — The following varieties are seen : 

Rachitic Coxa Vara. — Rachitic coxa vara does not occur as an 
independent expressio7i of rachitis, being associated with X-legs, 0-legs, 

1385 



1386 



THE SURGERY OF DEFORMITIES 



flat food, scoliosis, etc. Its local symptoms do not differ from those of 
the other forms of the deformity ; it is usually bilateral. 

It must be diagnosticated from the congenital form. This, accord- 
ing to Hoffa,^ may be done hy means of the Rontgenogram. 

The tendency in rachitic coxa vara is toward spontaneous return to 
the normal. 

Static Coxa Vara. — Static coxa vara means a disproportion be- 
tween the weight bearing capacity of the neck of the femur and the 
load placed upon it. This occurs in young persons devoted to certain 
kinds of occupations v/hich demand many hours in the erect position 
(waiters, gardeners, 
etc.). It is prob- 
able that the de- 
formity occurs only 
in persons whose 
bones are deficient 
in 'lime salts. 

Bade^ devotes 
considerable space to 
the discussion of the 
changes in the head, 
neck and trochanter" 
of the femur coinci- 
dent to static coxa 
vara. He ends .by 
stating that the neck fig. 675. 
is always hcnt down- 
ward and tacliward 
and that in come cases a partial luxation of the head is also present. 

The clinical course of static coxa vara is characteristic. The patient 
usually seeks advice because of lameness with more or less pain in the 
knee and foot ; flat foot is a very common complication. 

Objectively, the most striking features are restricted adduction, 
inward rotation, and the ahnormally high position of the trochanter. 
Extension of the limb is normal. 

The prognosis is not unfavorable; healing with fair function often 
occurs. However, the disturbances are likely to persist for a long 
time. 

The treatment during the painful stage demands complete rest with 
extension. The latter is important. If the Rontgenogram reveals 




Schematic Presentation of the Head Epi- 
physes IN Congenital (left) and Eachitic Coxa 
Vara (Hoffa). 



DEFORMITIES OF THE LOWER EXTREMITIES 1387 



changos in the bono witli det'ormity, correction under narcosis, stretch- 
ing of the muscles, and the employment of the gypsum dressing is 
indicated. In severe cases, bloodless infraction may be emploj-ed. 
For the purpose, the pelvis is firmly fixed; the first abduction 
maneuver tears the adductors. Next, the fist of an assistant is forced 
into the groin and makes pressure against the head of the bone; the 
hands of the operator grasp the shaft of the femur near the trochanter 
and execute forcible abduction; a characteristic crushing sensation is 
imparted to the hands as the infraction occurs. The limb is placed 

in extension for six 
weeks. Lorenz* 
strongly recommends 
the method. Hof- 
meister^ reports a 
number of failures. 
The Moody opera- 
tive measures of re- 
lief are taken up in 
connection with Op- 
erations on Bones and 
Joints (Part IV, 
.chap. vi). 

Traumatic Coxa 
Vara. — Traumatic 
coxa vara is discussed 
in connection with 
fractures of the neck 
of the femur (Part 
IV, chap. vi). 
Inflammatory Coxa Vara. — Inflammatory coxa vara results from 
infections of the neck of the femur, of which tuberculosis and infec- 
tious osteomyelitis are the most common. It also occurs as a part of 
arthritis deformans of indefinite origin. 

Coxa Vara from Other Causes. — Coxa vara from other causes 
includes the cases in which the deformity is secondary to osteitis fibrosa, 
senile osteoporosis, the formation of bone cysts, etc. That is to say, 
any of the lesions common to bones may occur in the neck of the 
femur and be manifested by a more or less distinct clinical picture of 
coxa vara. 




Fig. 676.— Eontgenogram of Coxa Vaka. 



1388 THE SURGERY OF DEFORMITIES 

COXA VALGA 

Coxa valga may be defined as the opposite condition to coxa vara, 
in which the angle of the neck of the femur to the head is increased 
and the shaft is near a straight line with it. According to Preiser," 
the upper end of the femur is twisted forward and the acetabulum is 
distorted laterally. The condition is not common. Its underlying 
causation is similar to that of coxa vara, except perhaps that consti- 
tutional peculiarities are more often responsible for it than obtains in 
connection with the reverse deformity. On the other hand, Lange 
has observed coxa vara on one side and coxa valga on the other in the 
same person. 

The treatment consists in massage, gymnastics, resistance movements, 
etc. Operative correction is rarely necessary, 

GENU VARUM 

Genu varum is the opposite of genu valgum (X-legs). The thigh 
and leg form a bow the convexity of which is outward and its apex 
corresponds to the level of the knee joint. In X-legs the anatomical 
cause of the deformity is fixed near the knee joint, while in genu 
varum it is located l^oth above and below the joint, i. e., in the thigh 
and in the legs. 

The participation of the femur and the bones of the legs is char- 
acteristic of genu varum and distinguishes it from the usual rachitic 
deformation of the bones of the legs alone, which is more properly 
designated las crura vara. 

The causation of genu varum is similar to that of valgum, i. e., 
rachitis, exudative diathesitis, osteomalacia and congenital lues. 

Genu vanim is generally symmetrically bilateral. The degree of 
deformity is readily outlined with a pencil on a sheet of paper. Chil- 
dren with genu varum walk with a characteristic waddling gait, which 
the laity call "tying knots," "crossing toes," etc. As a rule, the 
condition disappears by itself. 

The treatment is at first directed toward correction of the rachitic 
tendency. Although local treatment is not always necessary, most 
orthopedists place the legs in removable splints, which make correc- 
tional pressure and are worn at night. The employment of flat foot 
plates during the day is also helpful. If the deformity does not show 
a tendency to correct itself, mecha/riical or manual modeling redress- 



DEFORMITIES OF THE l.OWEK EXTREMITIES 1389 

ment, under narcosis, may be practiced. With a little patience this 
succeeds without actually fracturing- the bones, the femurs and the 
bones of both legs being straightened at one sitting. When this does 
not succeed, bloodless fracture or infraction at the dome of the de- 
formity is indicated. Bade^ does this over a wedge, such as is used 
for reposition of congenital dislocation of the hip. In very severe 




Fig. 677. — Typical Pull Bow Legs (Rymmers' Belle\Tie Hospital case). 

eases linear or cuneiform osteotomy is indicated. These are, of course, 
also executed at the highest point of the deformation. The principle 
of the operation is illustrated in connection with osteotomy for the 
relief of coxa vara (Part IV, chap. vi). 

GENU VALGUM 
Genu valgum, also known as knock knee, X-legs, and K-leg, presents 

A DEFORMITY OF THE LOWER EXTREMITY CHARACTERIZED BY ANGULATION, 
THE APEX OF WHICH CORRESPONDS TO THE KNEE JOINT. As tO the 



1390 



THE SURGERY OF DEFORMITIES 



various theories of the causation of genu valgum, that of Mikulicz,^ 
who attributes it to pathological conditions of the bones entering into 
the knee joint, is probably correct. The underlying cause in children 
is rachitis attended with an irregular ossification of the epiphyses. A 
second cause is exudative diathesitis, i. e., a constitutional osseous 
defect. This aspect of the subject is extensiveh' discussed by Bade,' 
who presents a series of Rontgenograms showing the bony lesions 
responsible for the deformity ; one of these, in which tlie genu valgum 




Fig. 678. 



• RONTGENOGRAM OF GeNU VaLGTJM DuE TO CHANGES IX THE LOWER 

Femoral Epiphysis. 



is due to changes in the epiphysis, is shown in Figure 678. Additional 
valuable information is obtainable from the work of Lange^ and of 
Kirmisson.** Bade' quotes Frolich as expressing the opinion that a 
certain number of the deformities are due to chronic staphj^lococcus 
osteomyelitis. It is certain that the genu valgum of adolescence is not 
satisfactorily explained on the basis of posture alone, and that an 
insidious chronic inflammatory process, such as Frolich speaks of, may 
well be the underlying cause. 



DEFORMITIE!^ OF THE LOWER EXTREMITIES 1391 



The sijniptoiits of genu valgum are clear enough. The knee johit 
protrudes inward. Tlie degree of the deviation is easily made out by 
measuring the distance between the malleoli with the patient standing 
erect. With the patient lying down, the inner condyles of the two 
legs are apposed and an outline of the limbs is drawn on a sheet of 
paper. The defoi-niiiy is often combined with bending of the tibia 
with the concavity inward. In genuine genu valgum the deformity 

disappears when the 
knee is flexed. The 
precise location and de- 
gree of the deformity 
is readily recognized in 
the Rontgenogram. 

The treatment o f 
genu valgum relates 
primarily to the gen- 
eral care of the patient. 
This is exceedingly im- 
portant. 

The local treatment 
is divided into the nom.- 
operative, the bloodless 
operative, and the 
hloody operation. 

The non-operative 
treatment of genu val- 
gum consists in the 
employment of a night 
apparatus which is 
constructed over a gyp- 
sum model (p. 1337) of 
the leg (Fig. 680). 
During the day, the 
apparatus shown in Figure 681 may be w^orn ; however, most ortho- 
pedists prefer that the latter be omitted. Spitzy^° makes the children 
squat in the ''Turkish position" for several hours each day and 
claims much for the measure. 

The bloodless operation is really a modeling redressment carried out 
in one sitting under narcosis (Lange^). This stretches the external 
lateral ligament and molds the articular ends of the femur and tibia. 




Fig. 679. — Genu Valgum (Johnson). 



1392 



THE SURGERY OF DEFORMITIES 



The method is followed by many failures. In its place, the epiphys- 
eolysis practiced by Codevilla^^ is now much used. This consists in 
firmly fixing the femur down to the epiphyseal line on a hard table, 
the rest of the limb extending over the edge of the latter. The operator 
forcibly presses the leg downward until the limb is straight ; this com- 
presses the medial side of the epiphj'sis and causes its external side to 
gape away from the diaphysis. The limb is encased in gypsum from 
one and one half to two months. The results following the maneuver 
are good. Arrest of growth of the bone has not been observed. 







1 


^^ 


il^^«^ii:r --- Hjik — "^^tSI 


Jl-Si 




^^KlI 


— ■■ ^^iiiiliii^ 







Fig. 680. — Night Splint fob Correction of Genu Valgum. 

The bloody operative method of relief consists in supracondyloid 
osteotomy, which is taken up in connection with Operations on Bones 
and Joints (Part IV, chap. vi). 



GENU RECTJRVATTJM 

In genu recurvatum the knee is bent backward. In some cases the 
joint surfaces undergo changes caused by an effort to adapt them- 
selves to the deformity (Delanglade^-). The condition is ascribed to 
lack of room during intra-uterine life, though it may also develop later 
in life after infantile paralysis, as the result of trauma and of chronic 
inflammatory conditions of the knee joint (lues and tuberculosis) 
which M^eaken its capsule and ligaments. It occurs in the paralytic 
stage of tabes dorsalis. 

This permits of a subdivision of the lesion as follows: (1) Con- 
genital; (2) paralytic; (3) atrophic; (4) osteogenetic, the last being 
again divided into traumatic and inflammatory. In the latter the 
joint may become ankylosed in the faulty position. 

The treatment is directed toward correcting the underlying cause. 
The emploj^ment of correctional apparatus, worn at night, is helpful. 
In severe cases arthrodesis may be necessary, while in cases of ankylosis 



DEFOKMITIES OF THE LOWER EXTREMITIES 1393 





in a faulty i)()sition, partial or complete arthrectomy may bo i)ractice(l 
(see Part IV, chap. vi). 

Habitual dislocation of the patella is also taken up in Part IV, 
chap. vi. 

DEFORMITIES OF THE FOOT 

Flat Foot. — Flat foot is applied to a luimber of anomalies of the foot 
in which the longitudinal arch is sunken and, when "loaded" with the 

weight of the body, comes in actual 
contact with the floor {pes planus) 
(Fig. 682). This condition, by itself, 
is not common. It is not apparent 
when the patient is seated. Very often 
the first indication of the deformity 
appears when the foot, with the patient 
standing, is viewed from behind and an 
abnormal prominence of the internal 
malleolus becomes discernible {pes 
valgus) . 

When both symptoms — the obliquity 
of the axis of the heel and the flatten- 
ing of the arch — are present, the con- 
dition designated as pes planus valgus. 
It is responsible for 80 per cent of the 
cases which consult the phj^sician for 
relief of "pain in the foot." 

In addition to this, a fourth de- 
formation of the foot comes under 
consideration, i. e., a sinking of the 
transverse arch of the foot. Normally, 
only the first and fifth metatarsal 
bones rest on the floor ; when the 
transverse arch is sunken the second 
or third forms its lowest point ; this is called pes transversoplanus. 
The causation of flat foot is both congenital and acquired. The 
congenital flat foot is rare and is ascribed to lack of room in the uterus, 
the postfetal flat foot is due to a variety of causes, such as malleolar 
fracture, scar tissue contraction, etc. However, as a matter of fact, 
it is due, in the vast majority of instances, to increased weight bearing. 
In childhood it may occur in connection with rachitis, malnutrition, 




Fig. 681. — Long Braces for Am- 
bulatory Correction of Genu 
Valgum. 



1394 



THE SURGERY OF DEFORMITIES 



anemia and infectious diseases. Of the direct causative factors, those 
relating to habit of locomotion and the use of improper foot wear are 
ver}- important. There is no doubt that the tendency to evert the foot 
while walking with the view to being graceful, the enforced "toes 
apart and heels .together" of military and school training, and the 
wearing of high heeled boots predispose to flat foot. It is the duty of 
parents to permit children to be ''pigeon toed" as long as possible. 
If "vw^ters, policemen, etc., were to take daily "pigeon toe" 
exercises the percentage of flat foot would be greatly reduced. 

The ohjective changes in flat foot are many and do not necessarily 
accord with the subjective disturbances. In addition to flattening of 
the plantar arch and the 
rotation in the long axis 
of the foot, the condition 
is attended with a dis- 
tinct protrusion of the 
sole of the foot beneath 
the navicularis, which is 
due to a downward dis- 
placement of this bone. 
In this stage of the 
lesion comparison of 
Rontgenograms taken 
with the patient stand- 
ing a n d seated is of 
great diagnostic value. 
Gradually the arch of 
the foot sinks more and 

more, the front of the foot widens and is elongated, so that the tendons 
are shortened and this leads to the formation of hammer toes. 

In the fully developed flat foot the arch is entirely obliterated. The 
skeleton of a foot deformed in this way is characterized by a complete 
change of architecture. The calcaneum is pronated and abducted, so 
that the fibular malleolus rests on the lateral edge of the former. 
The tuberosity touches the floor only with its median portion. The 
sustentaculum tali is broadened and moved backward. In the Ront- 
genogram the spongiosa of the bones of the tarsus is seen.t© be sepa- 
rated ; normally, that of the talus and calcaneum cover one another. 
The talus has moved forward and inward; its articular surface is no 
longer horizontal in the malleolar fork, while the navicularis, the three 




Fig. 682.- 



• Pes Planus - 
son). 



Flat Foot (John- 



DEFORMITIES OF THE LOWER EXTREMITIES 1395 



cu7ieiform and the cuboid rest on the floor. This causes changes in 
the relationship in the articular surfaces of the bones, which ultimately 
take on the form of a genuine arthrlfis deformans, with the formation 
of osteophytes. 

Flat foot may be present for years without giving rise to symptoms, 
and suddenly, after" a severe exertion, may develop an acute stage 
(trai())iatic flat foot). 

Tlio suhjeetive disturhances are not in accord with the stage of the 
deformity. Changes of slight degree may cause severe symptoms, and 
not infrequently a complete flat foot is presqpt without giving rise to 
discomfort. Earhf pain is usually present at three points; (1) at the 
inner edge of the sole in the course of the ligamentum tibiocalcaneo 
navicularis ; (2) on the back of the foot over the joint between the talus 
and the navicularis; (3) on the outer side of the foot from the attach- 

Cim III. 

Cun. II 

A »? / / Cun. I. 



Calcan 



Sin Cub. 
fars- 
Sulc peron long. 

Fig. 683. — PRoriLE View of the Skeleton op the Normal Foot, Showing the 
Anterioposterior Arches of the Foot. (After Merkel.) 

ment of the peroneus brevis to the external malleolus. In some 
patients the pain occurs along the entire length of the foot, apparently 
from straining of the medial interossei muscles, while others locate the 
pain at the heads of the metatarsal bones. Patients afflicted with flat 
foot are likely to /'turn the ankle" while walking. Many of them 
present the clinical triad, (1) difficulty in "getting under way," 
(2) better when "under way," (3) worse after being "under way." 
Very frequently, distressing pain occurs in the heel. 

Callus is often formed under the heads of the middle metatarsal 
bones. The sinking of the transverse arch is also attended with the 
localized "lightning pains" of 3Iorton's disease. The pain is prob- 
ably due to pinching of the plantar nerve as the arch gives way under 
the pressure of the superimposed weight. 

After a time, the extra duties placed on the musculature of the leg 




1396 THE SURGERY OF DEFORMITIES 

cause pain in the gastrocnemius muscles, and the tibia may also be the 
seat of dull pain. Pain in these parts may occur without pain in the 
foot. 

The twisting in the foot in the malleolar fork may modify the 

STATIC arrangement OF THE ENTIRE EXTREMITY AND PELVIS. Pain 

often develops beneath the patella and in the lateral ligaments of the 
knee; and the joint, in an effort to accommodate itself to the faulty 
position of the foot, undergoes compensatory deformation which, in 
severe cases, gives rise to arthritis deformans. A similar condition of 
affairs has been observed in connection with the hip and the sacroiliac 
joints (Preiser^^). 

The diagnosis of flat foot may be attended with considerable diffi- 
culty. It is not always easily separated from gout, rheumatism, and 
sciatica. 

Above all, the surgeon must not assume that flat foot is not present 
because the footprint shows the presence of a plantar arch. As in 
almost all afflictions, the history of the case is the most important 
determining diagnostic factor. In most of the cases the "pain triad" 
spoken of above is present. In addition to this, the various s^Tiiptoms 
presented under the head of subjective disturbances must be sought 
for. The examination of the foot tvear and observation of the patient's 
mode of locomotion are very important. 

Considerable assistance ls furnished hj the footprints. The normal 
outline is shown in figure 684A ; B shows the print made hj pes plano- 
valgiis. 

The treatment of flat foot is of great practical importance. In the 
early stages of the lesion, mas.sage, supination exercises with manual 
resistance, and the emploj-ment of properly fitting shoes will accom- 
plish the purpose. The inner edges of the soles of the shoes may be 
raised. 

As soon as the tendency toward valgus deformity appears, a prop- 
erly fitting arch support is fitted into the shoe; this is not a simple 
matter. The support is best fashioned by an expert orthopedic tech- 
nician. If necessary, the physician may prepare a g^'psum model of 
the foot, in the manner indicated on p. 1337, and forward it to the 
technician. Care is necessary in providing support in cases of flat- 
tening of the transverse arch of the foot, especially when this is com- 
plicated by Morton's disease (see Whitman") . The use of the support 
does not lessen the need for the emplo\Tnent of foot gATunastics, which 
include the exercises of EUi.s^' and Roth,'" and the use of the Zander 



DEFORMITIES OF THE LOWER EXTREMITIES ' 1397 

pendulum apparatus (p. 1341). Temporary relief may be obtained by 
the application of an adhesive plaster dressing. 

• In obstinate flat foot correction by redrcssment in narcosis is em- 
ployed as follows: The foot is "wobbled" over a padded wedge until 
it can be fully supinated with one finger ; it is then wrapped in cotton 





m. 




Fig. 684. — Foot riuxTs. A, Normal Print. B, Print of Complete Flat Foot. 
Both arches have collapsed (Johnson). 



and immobilized in gypsum (to the knee) in the corrected position. 
The patient is kept in bed for three days, at the end of which time he 
is alloAved to walk in the gypsum cast. At the end of from four to 
six wrecks the cast is removed and the usual after treatment is employed. 
When arthritis deformans is estaNished, redressment must be at- 
tained hy means of the osteaclast (Fig. 634). In some cases subcuta- 



1398 THE SURGERY OF DEFORMITIES 

neous section of the peroiici tendons is necessary. This is not as suc- 
cessful as cuneiform osteotomy. 

Cuneiform osteotomy for flat foot is not a difficult operation. With- 
out regard for joints or ligaments, a wedge is cut out of the tarsus 
with a chisel and mallet at the site of the navicularis, the base of the 
wedge corresponding to the plantar and inner aspect of the foot. The 
wedge corresponds to about two thirds of the width of the foot; the 




Fig. 685.— Skeletal Preparation of a Club Foot in an Adult (Lange). 

outer third is cut through with tlie chisel. If approximation of the 
cut bony surfaces does not accomplish the desired correction, additional 
sectors of bone are removed. The wound is closed and the foot is 
encased in g\'psum in the corrected position for eight weeks. The 
method gives excellent results. Both feet may be corrected at one 
sitting. 

The operative treatment of paralytic flat foot consists in primary 



DEFORMITIES OF THE LOWER EXTREMITIES 1399 



bloodless redressment of the deformity and secondary transplantation 
of tendons. The paralyzed tibialis posticus is replaced by the flexor 
hallucis or the peruiieus brcvis and tiic tibialis anticus is replaced by 
the extensor hallucis. The execution oi' llic tcciniie requires consider- 
able skill and a thorough knowledge of the anatomy of the parts. 

Kohler's Disease. — 
Kohler^' describes a con- 
dition observed in chil- 
dren that is character- 
ized by lameness and is 
easily confused with flat 
foot. T h e Rontgeno- 
gram reveals shortening 
and widening of the 
navicularis. The density 
of the bone is also 
markedly increased. The 
absence of atrophy dis- 
tinguishes it from bone 
tuberculosis. As the 
child develops the lesion 
undergoes spontaneous 
correction. 

Club Foot.— Club foot 
is a supination deform- 
ity of the foot. The 
inner edge of the foot is 
adducted, the foot as a 
whole is rotated inward, 
and the sole of the foot 
is supinated. As a rule, 
club foot also exhibits a 
tendency to point and 
presents a certain de- 
gree of plantar hollow. 
This is called pes equino- 
varus. Club foot is 
^ • either congenital or 

Fig. 686. — Single Congenital Club Foot. acauired 

A, Viewed from the front; B, Viewed from ^ ^ 

^gljin^^ Congenital Club 





1400 



THE SURGERY OF DEFORMITIES 



Foot. — The causation of congenital club foot is ascribable to 
heredity, that is, club foot appears in generation after generation 
of the same family. It is also present in conjunction with spina 
bifida (p. 1426), etc. However, the chief cause would seem to be 
abnormal intra-uterine pressure from lack of room and amniotic 
bands. The influence of abnormal pressure is known because of the 
occasional presence of the scars of decubitus ulceration in the newly- 
born. In addition to this, certain authorities consider intra-uterine 
poliomyelitis responsible for the congenital type of the deformitj^ 

The anatomical changes in congenital cluh foot (Fig. 685) ma.y be 
described as follows: The calcaneum is supinatod and rests on its 
outer edge, so that its 
axis forms a bow with a 
lateral convexitj^; it is 
shortened and is in the 
abducted position. Its 
sustentaculum is under- 
developed, while on its 
lateral side the trochlear 
process, which gives pas- 
sage to the tendon of the 
peroneus longus, is in- 
creased in size. The de- 
pression caused in the 
calcaneum by the in- 
creased tension of this 
tendon is deepened and 
is readil}'- traced to the 

surface of the cuboid. The talus is also supinated; its axis is 
twisted outward (convexljO? so that the outer side of its neck 
is lengthened and the inner shortened. The curve may be so 
acute that the tuberosity of the navicular is almost touches the 
internal malleolus. Indeed, in the adult neo-arthrosis is not 
infrequently formed in this situation, showing that the two bones 
have been in contact during weight bearing. The articular surface 
between the calcaneum and the cuboid is not perpendicular to the 
former, but is luxated inward. The foot as a ivJwle is rotated imvard 
in the malleolar fork, so that a portion of the body of the talus is 
luxated anteriorly. In the adult the joints show evidence of arthritis 
deformans and the deposit of osteophji:es. The kn*<e, the upper end 




Fig. 687. — Adhesive Plaster Support for the 
Correction of Club Foot (Whitman). 



DEFORMITIES OF THE LOWER EXTREMITIES 1401 

of the tibia, and the condyles of the femur show deformations, the 
result of excessive internal rotation ; and in the hip joint, the head of 
the femur undergoes a change in outline for the same reason. The 
soft parts on the inner side of the foot arc shortened ; the ligaments 
and the plantar fascia are shrunken. Of the muscles, the gastrocne- 
mius, the tibialis posticus and anticus are contracted, while the liga- 
ments, tendons and muscles on the outer side, especially the peroneus 
longus and the extensor digitoinim, are much stretched. 




Fig. 688. — Eedressmext of Clue Foot (Whitman). 



Occasionally, congenital club foot is found in genu A'algum. This 
peculiarity is possible onh' when the child is also rachitic. 

The clinical manifestations of cluh foot are quite in accord with the 
deformity (Fig. 686). The tread of the foot corresponds to its lateral 
edge or even its back. Adventitious bursae and large calluses fre- 
quenth' form in these .situations ; the former often suppurate. 

The treatment of congenital cluh foot is one of the most satisfactory 
attainments of modern surgery. It should begin within the first few 
days after birth, and at this time is a simple manual redressment. 
This consists in an attempt to ''roll the foot up." The malleoli are 
grasped with one hand and the foot is sharply twisted so that the 



1402 



THE SURGERY OF DEFORMITIES 



plantar arch is flattened; at the same time the toes are forcibly ele- 
vated. This maneuver is carried out several times daily. Presently, 
redressing adhesive plaster strips may he applied (Fig. 687). The 
mother or nurse mu.st be instructed to watch for disturbances of cir- 
culation. It is amazing how much may be accomplished by this simple 
means. 

Redressment in mircosis is carried out as early as the fourth week of 
life, although most orthopedists wait until about the tenth month. It 
is performed as follows : The foot is postured with its dorsum (area 
of the cuboid) resting on the summit of a padded wooden wedge, such 
as is used for bloodless reposition of the hip. The one hand of the 
operator grasps the heel, the other, the metatarsus, and the foot is 
forcibly bent into the normal position until the plantar hollow has 
entirely disappeared (Fig. 688). When this is accomplished the toes 
are forced toward the shin as far as possible and then {hut not until 
then) the tendo 
Achillis is suhcu- 
taneously sectioned 
(Preiser^^). The 
small tenotomy ^ 
wound is closed 
and the foot is 
postured as shown 
in Figure 689 ; or 
the leg may be at 

once placed in gypsum in the overcorrected position, as shown in 
Figure 690. The child must not he taken from the tahle until the 
toes are rosy in color. 

The gypsum dressing is left in situ for several weeks and is renewed 
every four or six weeks for from one half to one year following the 
operation. This is followed by the use of an ambulatory apparatus, 
such as is shown in Figure 691; its mechanism is explained in the 
legend. As soon as correction is attained the limb should be frequently 
massaged, the apparatus being arranged so that this may be done. 
Apparatus, such as the one shown in Figure 691, must be worn for a 
long time (j'cars). During this period correctional mechanotherapy 
may be used to advantage. 

In older patients the problem may be attacked in the same manner 
as in children. However, redressment is best executed in two sittings, 




Fig. 689. — Sayre's Apparatus for Talipes Equinus. 



DEFORMITIES OF THE LOWER EXTREMITIES 1403 

the teiido Acliillis boin*^ sectioned at the second one (v. Aberle'"). In 
these cases tlie danger of fat embolism comes into consideration. 

Of the so-called hloodij operations, that of Phelps'" and the radical 
cuneiform osteotomy have been abandoned in favor of the method of 
Ogston.-^ It is performed as follows: A curved incision is made over 
the talus and the greater part of its su,bstance (except the articular 
surfaces) is remoyed with the gouge and the chisel. Eventually, the 
walls of the bone are forcibly "caved in" and ihe foot is placed in the 




Fig. 690. — The First Application of Gypsum for Belief of Club Foot 

(Whitman). 

corrected position. This is followed by immobilization in gypsum. 
The Rontgenogram shows that much of the bone substance is repro- 
duced, but without deformity. The results of tlie measure are 
excellent. 

Acquired Club Foot. — Acquired club foot follows malleolar frac- 
tures, luxations of the talocrural or mediatarsal joints, osteomyelitis, 
and contraction of scar tissue. It also occurs in connection with 
poliomyelitis (70 per cent) and spastic paralysis. The treatment 
varies wdth the cause. The traumatic forms are treated by redress- 



140-i 



THE SURGERY OF DEFORMITIES 



ment, and, if necessary, osteotomy is performed. The paralytic form, 
is corrected and this is supplemented by iendan elongatio^i and tendon 
trans plant at ion. In cases of total paralysis, arthrodesis, as indicated 
on p. 857, may be resorted to. 

Pes Cavus — Hollow Foot. — Hollow foot, or claw foot (Fig. 692), is 
a pathological increase of the plantar arch. The deformity is rarelj'' 
present alone and is usually complicated by pes calcaneus or equinus. 
The congenital form may coexist with spina hifida (also the occult 







^^^^ 




^H 




**^^S 




^ 


1 


w% 








H Ik^^ 


^H 








111 


H'i 




1 


^^^^ ^ 


m 


^1 


ft 


1^1^^ 


3 




Fig. 691. — Ambulatory Correction.\l Apparatus for Eelief of Club Foot. 

A, The lateral foot hinge moves in a slot, so that the foot is forced toward the 
valgus position at each step. B, This is aided by a second hinge situated lower 
down. The apparatus is removed at night. 

form). Its association with chorea, myxedema and neurogenous con- 
tractures of the plantar fascia seems to be established (Preiser^®). 
The treatment consists in forcible red'ressment, as for club foot. In 
severe cases corrective cuneiform osteotomy of the na%'icularis is per- 
missible. 

Pes Equinus. — In pes equinus (Fig. 693) the deformity consists in 
an abnormal plantar flexion of the foot. 

Its causation is congenital, i. e., it may result from intra-uterine 



DEF0KM1T1E« OF THE LOWER EXTREMITIES 1405 





If 


\ 




^ 


\ 




\^> .Ji 


J^""-^ 


"^-^^^ 


w 



Fig. 69i 



Pes Cavus. 



pressure. In most instances, however, it is acquired. The acciuired 
form is divided into those resulting t'l-om cicatricial contracture; from 

arthrog.enous causes, .such as 
gonorrhea, tuberculosis, lues, 
and polyarthritis; the traumatic 
(following malleolar and tarsal 
fracture) ; the neuroejenous; and 
the compensatory. In persons 
confined to bed for a long time it 
develops from pres-sure of the 
bedclothes. The majority of the 
cases are of neurogenous origin, 
being due to either spasms of the 
muscles of the calf (spastic 
paralysis, hemiplegia, etc.) or to 
flaccid paralysis of the anterior 
tibial group of muscles (anterior 
poliomj-elitis) . The compensa- 
tory form occurs in connection with shortening of the limb from 
various causes, including congenital luxation of the hip. 

As the result of locomo- 
tion; the sole of the foot 
over the heads of the 
metatarsal bones becomes 
calloused, and in some 
cases the patient walks on 
the dorsal side of the toes. 
The talus is luxated out 
of the malleolar fork. 

The treatment of the 
congenital form is similar 
to that of club foot (p. 
1401). In the acquired 
form, efforts at its pre- 
vention should be in- 
cluded in the care of the 
cause. In the paralytic 
form, correctional appa- 
ratus and the emplovment _ 

„ ,1 • • • t' i 1 Fig. 693. — Compensatory Pes Equinus, Due 

ot prothesis is indicated. to Shortening of the Leg. 




1406 



THE SURGERY OF DEFORMITIES 



In the severe forms, redressment under narcosii? and section of the 
tendo Achillis are employed. The latter may have to be supplemented 
by tendon lengtheming and by tendon transplantation. In complete 
paralysis, arthrodesis of the ankle 
joint (p. 857) is justifiable. In the 
compensatory form, locomotion is 
aided by prostheses of various kinds. 
One of these is shown in Figure 694. 

Pes Calcaneus. — Pes calcaneus 
(Fig. 695) is a rare deformity of the 
foot characterized bj^ excessive dor- 
sal flexion. According to Lange," of 
13,000 deformities of the foot, 7 
were congenital and 31 were acquired 
cases of pes calcaneus. Preiser^^ 
saw 7 in 5,000 cases. Fig. 694.— Sketch of Prosthesis 

_, , - ., ^ FOR COMPEXSATORY PES EqUINUS 

Pes calcaneus may be congenital (Cork Inlay). 





Fig. 695. — Pes Calcaneus (Wliitmau). 



DEFORMITIES OF THE LOWER EXTREMITIES 1407 



and is then due to iiitra-iiterine pressure; in these instances it is 
usually a part of a talipes valgus. 

The acquired form may be due to cicatricial contracture of the soft 
parts of the dorsum of the foot. However, it is usually due to inactiv- 
itjl of the Diusclcs of the calf. The latter may follow injury to the 

tendo Achillis, but is 
more frequently the re- 
sult of the paralysis 
coincident to ayiterior 
polioniijelitis. 

AVhen due to a spinal 
lesion the condition is 
readily studied. The de- 
formity is manifestly 
the outcome of the trac- 
tion of the unapposed 
activity of the dorsal 
flexors. When the 
paralysis of the muscles 
is not complete or their 
power is partially re- 
stored, the deformity is 
limited to a pure pes 
calcaneus. However, if 
the gastrocnemius is 
completely paralyzed, 
the "tug" of the dorsal 
flexors and of the short 
flexors of the sole causes 
the deformity to become 
a pes cavus. The an- 
terior portion of the 
foot sinks into extreme plantar flexion and the posterior main- 
tains the calcaneus deformity; in this way a pes calcaneo-excavatus 
(Chinese foot) is formed. If the peronei muscles are preserved, these 
drag the already deformed foot into a valgus position, so that the 
condition must now be designated as a pes calcaneo-excavatus valgus. 
The latter is the usual deformity seen in cases of spastic and con- 
genital pes calcaneus (Piirckhauer^^). 
The treatment of pes calcaneus varies with its enology. In the con- 




FlG. 696. — EONTGENOGRAM OF HALLUX VALGUS. 



1408 



THE SURGERY OF DEFORMITIES 




Fig. 697. — Hammer Toes. 



genital form the same principles are followed as are described in con- 
nection with club foot. The aim is at first of course toward over- 
correction. In some instances tendon plication (p. 1048) of the tendo 
Achillis is necessary (Lange'). In the poliomyelitis cases tendon 
transplantation, using the 
peronei muscles for the purpose, 
is advisable. In total paralysis 
redressment a n d arthrodesis 
may be practiced. 

Pes Adductus, or Metatarsus 
Varus. — This condition is often 
associated with s^'ndactylia and 
poh'dactylia. The hollow of the 
foot is much exaggerated and 
the first, second, and third meta- 
tarsal bones are strongly ad- 
ducted. The deformity- is due 
to contracture (neurogenous) of 

the extensor tendons and is reg-arded as congenital in origin (spina 
bifida occulta). The condition is readily corrected by means of manual 
redressment or by the help of the redresseur (Duncker,-^ v. Frisch^^). 

Hallux Valgus (Fig. 696).— This 
very common deformit}' is charac- 
terized by abduction of the great 
toe. It may be congenital, but 
usually is caused by pointed shoes. 
The position of the toe causes the 
head of the metatarsal bone to pro- 
trude, and, as the result of pressure 
(especially when a pes planus is 
also present), the bursa over the 
joint becomes inflamed and pain- 
ful. Ultimately the joint itself 
develops a typical arthritis de- 
formans, with the formation of osteophytes and joint mice. In the 
early stages proper adjustment of the boot is followed by relief. In 
most cases it is necessary to open the joint (by means of a curved 
inci.sion) and remove the bony deposits (Wilson-"). This relieves the 
pain, but does not correct the deformity; the latter is readily achieved 
bv excision of the head of the metatarsal bone. After the wound is 




Fig. 698. — Saxdal With Ela.stig 
Baxds for the Treatment of 
Hammer Toes. 



DEFORMITIES OF THE LOWER EXTREMITIES 1409 

closed the toe is maintained in tlie corrected position (in gypsum) for 
three weeks. Redressment of the pes planus may be executed at the 
same sitting. 

Hammer Toe. — Hammer toes ma^' be congemlal, but are usually due 
to short hoots or develop as a part of flat foot. The faulty position of 
the toe (Fig. 697) exposes it to undue pressure, with the result that 
"corns" and chronic bursitis make the life of the patient miserable. 
When several toes are affected, the apparatus shown in Figure 698 
may be advantageously worn at night. Amputation relieves the situ- 
ation, but is not practiced unless subcutaneous section of the flexor 
tendons and forcible redressment fails to correct the deformity. 

BIBLIOGRAPHY 

1. FiORANi. Bade in Langre's Lehr. d. Orth. Chir,, Jena, 1914. 

2. HoFFA. Bade in Lance's Lebr. d. Orth. Chir., Jena, 1914. 

3. Bade. Same as No. 1. 

4. LOREXZ. 8tli. Cons:, a. d. Gesell. f. Orth. Chir., 1909. 

5. HoFMEiSTER. In Joachimsthal's Handb. f. Orth. Chir. (Lit. to 1902). 

6. Preiser. Zeilscbr. f. Orth. Chir., xix. 

7. Lange. In Wilms- Wullstein, Lehrb. d. Chir, 

8. Mikulicz. Same as No. 1. 

9. KiRiiissox. Rev. d. orth., 1903. 

10. Spitzt, Same as No. 1. 

11. Codevilla, 1st. Cong', d. Deutsch. Gesell. f. orth. Chir. 

12. Delanglade. Rev. d' ortho])., 1903. 

13. Preiser. Statisehe Gelenkerkrank, Stuttgart, 1911. 

14. Whitman. Orthop. Surg., Phila. and N. Y., 1917. 

15. Ellis. Edinb. Med. Jr., 1889, 

16. Roth. Bnt. Med. Jr., 1883. 

17. KoHLER. See Stumme : Fortschr. auf , d. Geb. d. Rontgenstrahle xvi. 

18. Preiser. Same as No. 1. 

19. V. Aberle. Naturforsch Versamm, 1906. 

20. Phelps. See Whitman No. 14. 

21. Ogstox. Brit. Med. Jr., 1902. 

22. PuRCKHAUER. Zeitschr. f. Orth. Chir,, xxx. 

23. DuxcKER, Zeitschr. f. Orthop. Chir., xxx. 

24. V. Frisch. Wien. klin. Woch., 1912. 

25. Wn.S0N. Amer. Jr. of Orth. Surg., 1906. 



PART IX 
REGIONAL SURGERY OF THE SPINE 



CHAPTER I 
GENEEAL SURGICAL CONDITIONS 

By regional surgery is meant the application of the general prin- 
ciples laid clown in the first portion of this work to the various sectors 
of the bod}'. For instance, the invasion of the vertebrae by the tuber- 
cle bacillus, the spirocheta pallida, or by pyogenic bacteria is governed 
b}' the same laws as obtain in connection with the other bones of the 
bod}', yet certain signs and s3'mptoms are due to the location of the 
pathological process, and these must be met by special measures of 
relief. On the other hand, the simple disturbance of function in a 
given part does not express the character of the causative process, and 
this will escape recognition, unless the general laws are applied to the 
portion of the body under consideration. Deformity' of, and pain in, 
the spinal column may be regarded as evidence of a disease of the 
spine, but its intelligent treatment rests on the establishment of the 
character of the causative process; this can be arrived at only by 
taking into account those principles to which so much space in this 
work has been devoted ; it also explains why this has been done, and 
excuses, perhaps, the comparative meagerness of the space allotted to 
the surgery of special parts. The latter becomes comparatively easy 
when the subject matter of the general part has been mastered. It is 
manifestly impossible, in a work of this kind, to furnish a complete 
presentation of the various special branches of surgery. However, an 
effort is made to give the student and practitioner a basic, working 
knowledge to guide him in the field of his endeavor, and to so equip 
him that he will find less difficult the rest of the journey. 

INJURIES OF THE SPINE 

Injuries of the Spine Other Than Fractures and Dislocations. (For 
fractures, dislocations and fracture dislocations, see Part IV, chap. 
V.) — As stated in connection with the general considerations regard- 
ing regional surgery, special signs and sjTnptoms are the outcome of 

1413 



1414 



REGIONAL SURGERY OF THE SPINE 



the involvement of special parts, and consequently these parts are sub- 
jected to special diagnostic measures. As applied to the spine, these 
measures relate to the X-ray and the examination of the spinal fluid. 
The technic of the former is of course not properh' discussed here; 
aspiration of the spinal canal is, however, a surgical procedure, and 
as the characteristics of the spinal fluid have a bearing on almost all 





Fig. 699. — Eelationship Between a Line Drawn 
Across the Iliac Crests and the Interakcual 
Space Between the Fourth and Fifth Lumbar 
Vertebrae, the Point of Election for Lumbar 
Puncture (Frazier). 



conditions discussed in this part of the work, the technic of obtaining 
it is taken up at this time. 

In lumhar puncture (rachicentesis) the needle must be introduced 
below the cord and between the strands of the cauda e<:iuina ; therefore, 
it must be introduced between the second and the fifth lumbar verte- 
bra : the most desirable of the avenues of approach here is the inter- 



GENERAL SURGICAL CONDITIONS 



1415 



space below the third vertebra. A line projected from the summit of 
the crests of the ilia traverses, in most instances, the spine of the 
fourth lumbar vertebra (Fig. 699). The puncture is made in the 




Fig. 700. — Landon Mercurial Manometer (Frazier). 



median line. The equipment for the purpose consists of a manometer 
for measuring the pressure of the cerebrospinal fluid, two sterile test 
tubes, a solution of collodion, an applicator, a needle (preferably 
platinum), a hypodermic syringe, and a solution of 5 per cent iodin. 



1416 



REGIONAL SURGERY OF THE SPINE 



The needle may be equipped with a stopcock. Frazier^ thinks the 
Landon mercurial manometer (Fig. 700) meets the requirements. 

Lumbar puncture may be performed with the patient in the sitting 
or horizontal position. In suspected brain tumor the latter is prefer- 
able ; as a matter of fact, it should be employed in all instances. How- 
ever, both positions are shown (Figs. 701-702). The skin is first 
punctured with a hagedorn needle, following which the hollow needle 
is introduced into the slit thus made and directed mesially and slightly 
upward; transfixion of the dura is recognized by the sudden absence 




Fig. 701. — Proper Position for Lumbar Puncture in Recumbent Posture. 
Patient brought to edge of bed or table, limbs flexed to arch the lumbar spine. 



of resistance. The stylet is withdrawn and the fluid allowed to flow 
into the graduate; 5 c.cm. is enough for diagnostic purposes. The 
intraspinal pressure is determined by connecting the manometer with 
the needle. Finally the needle is withdrawn and the puncture is 
sealed with collodion. 

The changes in the spinal fluid are dependent upon the character of 
the inflammatory process, and may be said to be directly indicative in 
a number of lesions and helpful in others in a negative way. The 
technic of the laboratory examination is taken up extensively by 
Frazier.^ In view of the comparative newness of the procedure, it 
may be advantageous to consult the works of the men quoted in the 
bibliography (end of chapter), of which those numbered from 2 to 54 



GENERAL SURGICAL CONDITIONS 



1417 



inclusive refer to the subject. In this coniioctiou, the publications of 
Frazier' and Mestrezat"* are perhaps the most complete (they also 
present extensive bibliographies), especially that of the former, whose 
text, being in our own language, may be the most valuable to the 
English speaking student. It is perhaps wise at this time to call 
attention again to the fact that aspiration of the spinal cord is not 




Fig. 702. — Lumbar Puncture, Sitting Posture. 

The patient leans forward, resting elbows on thighs in order to arch the back 
and widen the interareual spaces. The needle is introduced in the interspiuous 
space below a line drawn across between the crests of the ilia (Frazier). 

without danger. This was brought out some years ago by Krause,^^ 
who observed two fatalities attendant upon the simple act of connect- 
ing the column of fluid in the canal with the manometer (that of 
Kronig), the patient being in the sitting posture. A similar unfor- 
tunate event occurred in the clinic of the writer in a case in which 
there was no lesion of the brain or cord, the puncture being made for 



1418 KEGIONAL SURGERY OF THE SPINE 

spinal anesthesia. The patient (a man of seventy) succumbed just as 
the fluid (5 c.cm.) was withdrawn, and before the anesthetic was 
injected. 

The after treatment is important. The seemingly slight procedure 
is at times followed by severe headache (which may last a week) and 
vomiting. The patient must stay in bed for twenty-four hours and 
anodynes be given, if necessar}^ Aggravation of symptoms is reported 
by many authorities and has been observed by the writer in several 
instances. If more than 5 c.cm. are withdrawn, the quantity evacuated 
must be replaced with sterile salt solution. 

Sprains or Distortions of the Spine. — These conditions are analo- 
gous to those of other joints ; they may, however, involve more or less 
damage to the cord. Because of the great mobility of the cervical and 
lumbar segments of the spine, these are most liable to be the seat of 
injuries of this sort. The injury may result from a blow or a fall, 
the force being transmitted in the long axis of the spinal column. The 
mechanism is similar to that provocative of fracture or dislocation, 
only less in degree. The injury implies either overstretching or more 
or less extensive laceration of ligaments; transitory disturbance of the 
relationship of the vertebral bodies to each other may be assumed. 
The injury to the cord, seen at autopsy, without any dissociation of 
relationship of the bony parts in this situation, is explainable on this 
assumption. These injuries may be contusion (myelitis hemorrhagica) 
and laceration of the cord and pia, or subdural hemorrhage, or both. 

The cli7iical manifestations of sprains include voluntary restriction 
of motion, pain on active motion, tc7iderness on pressure, and the 
absence of evidence of fracture or dislocation. The symptoms vary in 
accord with the severity of the injury. In severe cases the concom- 
itant cord disturbances give evidence of the seriousness of the lesion. 
These may be limited to a slight increase in tendon reflexes or may 
include grave interference with motion, sensation, and the functions 
of the bladder and the rectum. 

The diagnosis of sprain is per force based on the Rontgenogram 
findings, the only relatively accurate means by which the presence of 
fracture or dislocation may be excluded. The pain, the attitude of 
the head in sprains in the cervical region, and the absence of faulty 
alignment of the spinous processes and negative Rontegenological find- 
ings are to be considered indicative of sprain (Frazier^). The pres- 
ence of blood in the cerebrospinal fluid (obtained by lumbar puncture, 
is helpful. 



GENERAL SURGICAL CONDITIONS 1419 

A guarded prognosis is necessary from the fact that an apparently 
trivial injury may stand ultimately in a causative relationship to dis- 
tressing sequelae, such as traumatic, chronic spondylitis (Kiimel's 
disease), with grave defoi'mity and permanent impairment of function. 

The essential of treatment is rest, at first in horizontal fixation, 
and later in immobilization (see spondylitis. Part IX, chap. iii). 
The mode of applying the treatment is determined by the gravity 
of the injury, as shown by the clinical picture. Active motion 
involving great effort should not be permitted until the tenderness has 
entirely disappeared. 

Contusion of the Vertebeal Bodies or the Ligaments. — This 
condition is more often suspected than demonstrated clinically. When 
the spinal column has been subjected to trauma and a complete exam- 
ination, including the Rontgenogram and the findings in connection 
with the lumbar puncture, results negatively, the presence of a 
contusion may be assumed. Of course a sharp distinction between 
contusion and sprain is impossible. 

A contusion, like a sprain, provokes pain on motion ; tenderness is 
elicited by pressure over the injured area. The Rdntgenogram is, as 
stated, helpful only in a negative way. The exposure would have to 
be a very successful one and the negative interpreted by an experienced 
eye to be considered as decisive in a diagnostic sense. 

The treatment of a contusion of the spine must be carried out along 
the lines indicated in connection with sprain. Fixation should be per- 
sisted in until all the symptoms have definitely disappeared. A re- 
movable gj'psum jacket may be worn in cases in which the sjTnptoms 
are moderate in degree. Massage should not bei employed until the 
acute S3'mptoms have disappeared. On the other hand, heat, in the 
form of baking, relieves the pain, and, unlike massage, is without 
danger. 

Fractures and dislocations are taken up in Part IV, chap. v. 

BIBLIOGRAPHY 

1. Frazier. Sure:, of the Spine and Spinal Cord, Appleton, N. Y. and 

London, 1918. 

2. Alzheimer. Centrbl. f. Nervenk. Psveh. Berlin and Leipzig, 1907, xxx. 

3. Apelt. Berlin klin. Woeh. 1910, No.' 47 ; Arch, f . Psvchiat. 1910-1911, 

No. 46; Arch. f. Psyehiat. u. Nervenk. Berlin, 1908, No. 44. 

4. Babinsky. Rev. Neurol., Paris, 1914, No. 22; Bull, de la See. med. des 

hop., Paris, 1901,. No. 18. 

5. Bernard. Bull, de la Soc. med. des hop., 1908, No. 25. 



1420 KEGIONAL SURGERY OF THE SPINE 

6. Boas. Hospitalstidende, Copenhagen, 1916, lix. 

7. Blanchetiere. Comj^t. rend. Sac. de biol., Paris, 1909, Ixvi. 

8. ZiEGLER. Arch. f. Chir., Berlin, 1896, liii. 

9. "WiDAL. Compt. rend. Soc. de biol., Paris, 1900, Xo. 52; Bull. See, 

10. Williamson. Lancet, London, 1909, i. 

11. Zaloziecki. Deutsch. Zeitschr. f. Nervenk., Leipzig, 1913, Xo. 47; also 

Yogel, Leipzig, 1913. 

12. Wile and Kruif. Jr. A. M. A. Chicago, 1916, Ixvi. 

13. Westox. Jr. Med. Res., Boston, 1916, Xo. 34; Am. Jr. Insan. Bait. 

1915, Ixxi. 

14. Schwartz. St. Petersburg med. AVoch., 1910, xxxv. 

15. SiCARD. Bull. Soc. med. des hop., 1904, Xo. 21; Rev. neurol. Paris, 

1910, Xo. 19. 

16. Siiiox. Wien. klin. Woch., 1911, xxiv. 

17. Weed. Jr. Med. Res., Boston, 1914, xxxi. 

18. Thabius and Barbe. Rev. neurol., Paris, 1913, xx\-i. 

19. Quincke. Berlin klin. Woch. 1891, xxviii, and 1895, xxxii ; Deutsch. 

med. Woch., Leipzig, 1905, Xo. 31. 

20. Redlich. Zeitschr. f. Xeurol. and Psychiat., Berlin, 1910. 

21. Ross and Jones. Brit. Med. Jr., London, 1909, i. 

22. ScHLESiNGER. Wien. klin. Woch., 1915, xxviii. 

23. Reichmann. Deutsch. Zeitschr. f. Xer\'enk., Leipzig, 1911, Xo. 42; 

Miineh. med. Woch., 1912, Xo. 56; Deutsch. Zeitschr. f. Xervenk., 
Leipzig, 1912, xliv. 

24. RosENTHEiM. Jr. Physiol., Cambridge, 1907, Xo. 35. 

25. Plaut, Rehm und Schottmuller. Jena. 1913; Xeurol. Centrbl., 

Leipzig, 1906, xxv. 

26. Xagouchi. Jr. Exper. Med., Lancaster, Pa., 1909, xi. 

27. Xonne. Xeurol. Centrl., Berlin, 1908, xxvni; Deutsch. Zeitschr. f. 

Xervenk., Leipzig, 1910, xl; Deutsch. Zeitschr. f. Xervenk., Leipzig, 

1911, Xo. 42, also 1913, xlvii-xlviii, also 1909, Xo. 37; Arch. f. 
Psychiat. u. X'^ervenk., Leipzig, 1907-08, xliii. 

28. Oppenheimer. Monatschr. f. Psychiat. u. Neurol., Strassbourg, 1913, 

xxxiii. 

29. Peabody. Rockefeller Inst, for Med. Res., June, 1912. 

30. MoTT. Lancet, London, 1910. 

31. MoTT and Halliburton. Lancet, London, 1901. 

32. ilAGENDiE. Jr. de phys. exper. et path., Paris, 1827, vii. 

33. ;NL\rchand. Rev. de psych, et de psych, exper., Paris, 1903. 

34. Materhofer. Wien. klin. Woch., 1910, xxiii. 

35. Lee and Hinton. Am. Jr. Med. Sci., Phila., 1914, cxlviii 

36. Capelletti. Arch. Ital. di Biol., Milan, 1900, xxxv. 

37. DuBois and Xeal. Amer. Jr. Dis. Child., Chicago, 1915. 

38. Lange. Berlin, klin. Woch., 1912, xlix; Zeit. f. Chem. u. v. Gebiet., 

Leipzig, 1913. 

39. Kronig. Semaine med., Paris, 1897. 

40. Grulee and Moodt. Amer. Jr. Dis. Child., Chicago, 1915. 

41. Hoffman and Schwartz. Arch. Inat. Mer., Chicago, 1916. 

42. KOPETZKY. Zeitsch. f. Ohrenk. u. f. d. krank. d. Luftweg., 1913, Ixviii. 

43. Hopkins. Amer. Jr. Med. Sci., Phila., 1915, el. 

44. Kafka. Monatschr. f. Pvsch. und Xeurol., Berlin, 1910, xx\-ii. 

45. Kaplan. Amer. Jr. Insane, Bait., 1912-13, Ixix; X. Y. Med. Record, 



GENERAL SURGICAL CONDITIONS 1421 

1910; with Casamajor, Jr. Arch. Int. Med., Chicago, 1912; with 
McCielhui, Jr. Amer. Med. Assoc, Chicago, 1914, Ixii. 

46. KoLMER. lut'ect. Iiniiiiin. and Specific Therapy, Phila., 1915. 

47. HALLiiiURTOx. Jr. Physiol., Cambridge, 1889, x. 

tensive bibliograi)liy. 

48. Mestkezat. La liquide cephalo-rachidienne. Pans, 1912, with an ex- 

49. Mestkezat et Kogers. Comp. rend. Soc. de biol., Paris, 1909, Lxvi. 

50. Danuy and Blackfan. Jr. A. M. A., Chicago, 1913, Ixi. 

51. Fabritius. Monatschr. f. Psychiat. u. NeuroL, Berlin, 1912, xxxL 

52. Flexner. Jr. Exper. Med., 1917, xxv. 

53. Frazier. Jr. A. M. A., Chicago, 1915, Ixiv. 

54. GuMPRECHT. Deutsch. mcd. Woch., Berlin, 1900. 

55. Krause. Surg, of the Brain and Spinal Cord, N. Y. 1909. 



CHAPTER II 



SPINA BIFIDA 



Spina bifida, of the various congenital deformities of the vertebral 
column or spinal cord, is the only one of clinical importance. The 
term, which originated with Tulpius in the middle of the seventeenth 
century (Frazier^), is used in connection with those congenital 

DEFECTS IN THE VERTEBRAL COLUMN THROUGH WHICH SOME OR ALL OP 
THE CONTENTS OF THE VERTEBRAL CANAL 
PROTRUDE IN THE FORM OF A CYSTIC TUMOR, 

varying in size from that of a hazel nut 
to that of an infant's head, and contain- 
ing cerebral spinal fluid. As a rule, the 
skeletal defect is in the arches of the 
vertebrae, the tumor presenting pos- 
teriorly {posterior spina bifida) ; in rare 
instances, the defect is in the vertebral 
bodies, the tumor protruding anteriorly 
into the abdomen, pelvis or thorax {an- 
terior spina bifida) . 

The walls of the sac may be composed 
of one or all of the membranes {meningo- 
cele), or of the membranes, together with 
the cord and roots, the cerebrospinal fluid 
being in the subdural or subarachnoid 
space {meningomyelocele) , or the mem- 
branes and cord may protrude through 
the defect and the fluid may collect in the 
more or less dilated central canal {syringo- 
myelocele). Therefore, in spina bifida 
the defect maybe not only in the bone, but 
also in the cord and its membranes. The 

abnormal collection of cerebrospinal fluid is the important clinical 
factor. 

The congenital origin of spina bifida is no longer questioned; the 

1422 




Fig. 703. — Myelocele: 
Club Foot. 



SPINA BIFIDA 



1423 



pathological embryology is available in the works of v. Reckling- 
hausen,- Muscatello,^ Mouchet/ and others. 

In view of the confusion with regard to anatomical types of spina 
bifida, the following classification (that of Frazier') is submitted: 

1. Meningocele, a protrusion of the dura, or both dura and arach- 



SKIN AND SUBCUTANEOUS 
COVERING 



DURAL SAC 




ARTICULAR 
PROCESS 



SPINAL NERVE 



INTERVERTEBRAL FORAMEN 



PIA-ARCHNOID 



Fig. 704. — Diagram op AxATOiiicAX. Kelations of Meningocele (Frazier). 



noid, through a cleft in the vertebrae, the collection of fluid being in 
the subdural or subarachnoid space posterior to the cord (Fig. 704). 

2. Spina bifida occulta, really a variety of meningocele, except that 
the hernial protrusion is small, or hidden, or entirely lacking, and, 
therefore, on account of its slow development and the latency of its 



1424 



REGIONAL SURGERY OF THE SPINE 



symptoms, it demands special consideration both, as to treatment and 
prognosis. 

3. Meningomyelocele, a protrusion of the defective cord and ante- 
rior portion of the pia through a cleft in the posterior portion of the 

A.VASCULOSA 

SPINAL CORD _„ 

A. SEROSA 

A.DERMATICA 




SPINAL 
NERVE 



INTERVERTEBRAL 
FORAMEN 



DURA 



Fig. 705. — Diagram op Anatomical liELATiox.s of Myelomenikgocele (Frazier). 



vertebral column, the dura, the arachnoid, or the pia, the collection of 
fluid being almost invariably in the subarachnoid space, anterior to 
the cord (Fig. 705). 



SPINA BIFIDA 



1425 



4. Myelocystocele, or synufjomyeloccle, a protrusion of the mem- 
branes and the cord. In this variety, however, the collection of fluid 
is in the central canal of the cord, which is ^eatly distended, the cord 



PIA-ARACHNOID 



RIM OF CORD 
SUBSTANCE 



ARTICULAR 
PROCESS 



DURA 




INTERVERTEBRAL 
FORAMEN 



Fig. 703. — Axatomical Eelatio:cs op STiaNGOMVELOCELE (Frazicr). 

substance being atrophied and forming the inner lining of the sac 
(Fig. 706). 

Spina bifida anterior is a rare condition. In most cases the bodies 
of the vertebrae are defective, allowing the contents of the spinal canal 



1426 REGIONAL SURGERY OF THE SPINE 

to extrude, thus forming a cyst of the central nervous system, simulat- 
ing a pelvic or abdominal tumor (Fairbairn"). 

The symptoms of spina bifida fall naturally into three divisions, 
(1) the local symptoms due to the mere presence of the cystic protru- 
sion; (2) the nervous phenomena caused by compression or degenera- 
tion of the cord, cauda equina, or nerve roots; (3) the symptoms due 
to associated malformations and defects. 

Since the tumor is filled with cerebrospinal fluid and is in direct 
communication with the spinal and cerebral subarachnoid spaces, its 
quantity is variable. The size of the tum.or is of course influenced by 
the position of the little patient, diminishing in size as the child is 
placed in the supine or elevated pelvic posture; its volume is tran- 
siently increased during forced expiratory acts such as coughing, 
sneezing or laughing. The degree of fluctuation depends upon the 
tension of the fluid and this in turn is dependent upon the dimensions 
of the defect. With a free communication into the spinal canal, the 
fluid may be forced into the canal ; this is fraught with great danger 
of fatal cerebral compression*. Fpazier'- reports that he witnessed an 
incident of this sort. 

Inasmuch as the spinal cord and roots are involved in all forms of 
spina bifida except the simple meningocele, the nervous phenomena 
play an important part in the clinical manifestations. They consist in 
motor, sensory, and trophic disturbances and vary according to the 
location of the anomaly «and the degree of compression or degeneration 
of the cord substance. 

Of the cord symptoms, the motor are the most pronounced. These 
manifest themselves in the form of complete paraplegia with secondary 
contractures and paralysis of the bladder and rectum and terminal 
atrophy. Talipes, in one form or another, is an almost invariable 
accompaniment (Fig. 703). In addition to this, deformity of the 
vertebral column as a whole is not uncommon (Plagemann'^). Hydro- 
cephalus is a prominent feature in many cases of spina bifida, and 
anencephalus, absence of cerebellum, gliosis, diastematomyelia and 
syringomyelia are net rare (Frazier^). 

Deformities and defects in remote portions of the body are not 
unusual ; of these, congenital dislocation of the hip, syndactylia, poly- 
dactylia, polymastia, the absence of ribs, and herniae of various kinds 
are the most frequent. 

Spina bifida occulta possesses clinical significance from the fact that, 
in addition to the external changes at the site of the defect, the con- 



SPINA BIFIDA 1427 

dition is associated ivith Icsi&ns such as hypertrichiasis, telangiectasis, 
pigmentations, and nervous disorders, which often appear between the 
tenth and twentieth year of life, when the membraneous band between 
the cord and the skin begins to compress or to make traction upon the 
spinal cord or nerve roots. These nervous sjTnptoms consist of motor, 
sensory and trophic disturbances of the lower extremities and paraly- 
sis of the bladder and rectum. Defects and malformations of other 
parts of the body are very common with spina bifida occulta. Among 
these is diverticulum of the Jbladder (Pfanner^). 

Spina bifida anterior, though not common, should be borne in mind 
during operations for the relief of abdominal and pelvic tumors, the 
origin of which seems to be obscure. As a rule, the condition is not 
discovered until the symptoms due to pressure of the tumor, such as 
pain, chronic ileus, obstinate constipation, frequency in micturition, 
etc., lead to exploratory exposure (Sawicki,^ Tilp,^° Robinson," 
Neugebauer,^- and Kroner and Marchand^^). The presence of other 
malformations and of a dimple covered with hair in the sacral region 
may awake suspicion. 

The diagnosis of spina bifida, except for the occult and anterior 
varieties, is comparativeh' simple ; however, the protrusion must be 
differentiated from dermoids, sacrococcj^geal teratomata, lipomata, 
and ischiatic hernia. On the other hand, the presence of a congenital 
hernial protrusion, rapid in its growth, situated in the median line, 
round or oval in contour, soft in consistency, fluctuating and varying 
in size in accord with the posture of the patient, should not leave much 
room for doubt as to its nature, especially when the defect in the spinal 
column is palpable. In spina bifida occulta the diagnosis is not easy. 
The Rontgenogram may be helpful and, as already stated, the coexist- 
ing malformations may direct attention to the associated condition. 
The anterior variety is still more difficult of recognition. The Ront- 
genogram is of real value, as shown in a case reported by Kelly {see 
Frazier^). 

In the treatment the selection of cases suitable to operative measures 
of relief is of prime importance. Frazier^ thinks operation should be 
deferred until after the first year of life, unless rupture threatens, 
when it may be undertaken earlier. The contraindications to opera- 
tion are hydrocephalus, coexisting irreparable deformities, paralysis 
of the sphincters, and paraple^a. Hydrocephalus is regarded as a 
contraindication by Broca," Muscatello,^ Frazier^ and others. The 
case of Kauseh, quoted by Frazier,^ in which the hydrocephalus was 



1428 



REGIONAL SURGERY OP THE SPINE 



taken care of by another operation, does not affect the general rule. 
As to paraplegia, the writer agrees with Hildebrand,^^ who says that 




Fig. 707. — Operation for Spina Bifida. 

The dotted line around the neck of the sac represents the point at which sac is 
to be amputated (Frazier). 

cases of this sort "shoiild.be left alone and should be allowed to die; 
in fact, the sooner they die the better." 

Of the t.ypes, the meningocele is the most favorable for operation. 
Spina bifida occulta should be subjected to operation onl}^- mlien symp- 



SPINA BIFIDA 



1429 



toms develop. Syringomyelocele may be operated upon when the 
tumor increases rapidly in size and is in danger of rupture. The 
meninyomyelocele is the least satisfactory to operate upon. 

In discussing the treatment of spina bifida, Frazier^ states that in 
children who have reached the age of two months, in whom there is 
no paralysis or hydrocephalus and when the sac is covered with 




Fig. 708. — Operation tor Spina Bifida (continued). 

The aponeurotic flaps are reflected and closed in the median line with a con- 
tinuous catgut suture, a (Frazier). 



healthy skin, the injection of Morton's fluid is justifiable, as it may 
accomplish the purpose and obviate the necessity for radical and more 
dangerous operative measures of relief. 

The operative methods of relief include the use of musculofascial 

flaps (Bayer^^), the transplantation of a flap from the fascia lata 

(Brodmann^'), a periosteal flap (v. Bergmann^^), the use of a bone 



1430 



REGIONAL SURGERY OF THE SPINE 



transplant (Zenenko/^ Albee-"), and fracture of the bases of the verte- 
bral arches and transference of them to the median line (Babcock^^). 
The method briefly described here may be regarded as indicating the 
principles involved in operative repair of the lesion. For elucidation 
with regard to the osteoplastic methods, the reader is referred to the 




Fig. 709. — Operation for Spina Bifida (continued). 

The third layer in the closure of the defect is repaired by the mobilization of 
the muscles on either side of the defect, -which are secured in the median line with 
interrupted catgut sutures, a (Frazier). 



bibliography as stated above. Frazier V method (which he states is 
generally credited to Bayer^*') may be described as follows: 

A U-shaped flap is dissected up and the cyst enucleated, as shown in 
Fig. 707, which also shows (dotted line) where the sac is amputated; 
the opening in the sac is closed with catgut. An incision is made in 
the sheath of the erector spinae muscle around the margin of the 



SPINA BIFIDA 



1431 



hernial orifice, extending 2 cm. above and below it, liberating two 
lateral tlaps, whit'li are reflected over the hernial opening and a])prox- 

imated in the center with a 
continuous catgut suture 
(Fig. 708). If the muscle 
cannot be approximated 
without undue tension, 
vertical liberating incisions 
are made on either side of 
the hernial opening. The 
muscle is the n approxi- 
mated in the manner 
shown in Fig. 709. Next, 
the vertical arms of the 
U-shaped incision are ex- 
tended upward ; a flap is 
dissected from the apo- 
neurotic covering of the 
muscle and this is turned 
down over the site of re- 
pair (Fig. 710) and held in 
place with interrupted 
chromic gut sutures. 
Finally, the skin flap is 
replaced and held in place 
with silkworm gut sutures. 
The operation may be per- 
formed through a single, 
vertical, median incision. 
If the parts are badly 
nourished, a free fat and 
fascia transplant from the 
fascia lata may be used in 
place of the one turned 
down from above the de- 
fect. In myelomeningocele the sac is opened by a transverse incision, 
a portion of it is excised and the roots and ganglionic tissue returned 
to the canal. 

Regarding operative prognosis, Frazier^ places the mortality at 
about thirty per cent. 




Fig. 710. — Operation for Spina Bifida 
(continued). 

The muscle layer is rcenforeed by the reflec- 
tion of a U-sliaped aponeurotic flap from 
above, secured in place with interrupted 
sutures (Frazier). 



1432 REGIONAL SURGERY OF THE SPINE 

In the after treatment the proximity of the operative field to the 
anus calls for the exercise of great vigilance as regards accidental 
infection. 

BIBLIOGRAPHY 

1. Frazier. Surgery of the Spinal Cord, Apple'.on, N. Y. and London, 

1918. 

2. Recklinghausen. Virchow's Arch., 1886, ev. 

3. MuscATELLO. Arch. f. klin. Chir., Berlin, 1902, Ixviii. 

4. MouCHET. Traite de Chir., Paris, 1913. 

5. MooRE. Surg. Gyn. Obst., Chicago, 1905, i. 

6. Fairbairn. Jr. Obst. and Gyn., Brit. Emp. London, 1911, xx. 

7. Plagemann. Deutsch. Zeitschr. f. Chir., 1911, ex. 

8. Pfanxer. Wien. klin. "Woch., 1914, xxvii. 

9. Sawicki. Brezgl. chir. i kinek. 1914, xii. 

10. TiLP. Verh. d. deutsch. path. Gesel., Jena, 1912. 

11. Robinson. Tr. Clin. Soe. London, 1903, xxxvi. 

12. Neugebauer. Brezgl. chir. i ginek. 1912, vi. 

13. Kroner und Marciiand. Arch. f. Gynak., Berlin, 1884, xvii. 

14. Broca. Rev. d' Orthoped., Paris, 1895, vi. 

15. HiLDEBRAND. Arch. f. klin. Chir., Berlin, 1893, xlvi. 

16. Bayer. Prag. med "Woch., 1892, xvii. 

17. Brodmann. Beitr. z. klin. Chir., Tubingen, 1911. 

18. V. Bergmann. Internat. Clinic, Phila., 1899, 9th ser., ii. 

19. Zenenko. Radikalnaya op. pri vrozhd. krestsovikh. spinnomozgovikh. 

grizhakh. Petrograd, 1895. 

20. Albee. Bone Graft Surg. Saunders, Phila, and London, 1915. 

21. Babcock. Penn. Med. Jr., 1910-1911, xiv. 



a 






CHAPTER III 

SPONDYLITIS 

Pott's disease is a term applied to the manifestations incident to 

DESTRUCTIVE CHANGES IN THE BONES AND JOINTS OF THE VERTEBRAL 

COLUMN. The term has been obtruded into the literature since 1779, 
when Pott first described an afifliction of the spinal column attended 
with deformity, pain, and paralysis. At his time and, indeed, for a 
considerable period of time after him, the character of the causation 
was not understood. For many years all destructive conditions in this 
situation were regarded as tuberculous in character and, as a matter 
of fact, most of them are ; however, a larger number of them are due 
to infections of other kinds — lues, pneumonococcus, typhoid bacillus, 
pyogenic bacteria, etc. — than is generally believed even today. The 
term ' ' Pott 's disease ' ' should disappear and a terminology be employed 
indicative of the kind of process involving the 'bones and joints, such 
as tuberculous, typhoid, pyogenic or luetic spondylitis. 

When spondylitis as a whole is viewed from this standpoint, it 
becomes patent that the changes which take place in the hones and 
joints of the vertebral column do not differ histologicallij from those 
incident to the invasion of a similar provocative factor in the other 
parts of the hodij, except perhajps inasmuch as the blood supply varies 
from that of other parts (Part II, chap, x), a conception which 
should rob the problem of some of its complexity and materially aid 
the student in understanding the pathological processes in the situation 
under consideration. 

Farther than this, the general symptomatology of inflammatory 
processes in the vertebral column is the same as that attendant upon 
similar lesions in the other bones and joints, and this is also true with 
regard to the diagnosis and the general principles of treatment. 
There remain, then, to be considered only the special symptoms — the 
outcome of the site of the lesion, the special diagnostic measure to be 
addressed to it, and the special efforts at relief demanded. 

The special symptoms of spondylitis relate to pain, loss of function, 

1433 



1434 



REGIONAL SURGERY OF THE SPINE 



deformity, and secondary complications, the latter being divided into 
abscess formation and paralysis. 

The pain of spondylitis is rarely localized in the region of the dis- 




FiG. 711. — Spondylitis in the Lower Dorsal Eegion. 

Six vertebrae are partially destroyed. The abscess has lifted the anterior liga- 
ment and is making l)ackward pressure on the cord. The cord is flattened. Com- 
plete paralysis was present. 



ease, but is referred to the front and sides of the body, to a location in 
accord with the site of the lesion, such as the side of the face, the neck, 
the thorax, the ahdomen, or the region of distribution of the sciatic 

nerve. 



SPONDYLITIS 



1435 



Impairment of the function of the vertebral column is expressed by 
restriction of voluntary movements of the limbs, or of the motility of 
the spine, due to contracture of muscles in an effort to assume a 
posture which relieves pressure, and because of reflex spasm. 

Deformity (Fig. 711) is fundamentally the expression of changes in 
the form of the diseased bones and the intervertebral joints. The 

deformitj' may present an 
angular projection 
(k^-phos) or may consist 
simply in lateral or an- 
teroposterior distortion. 

Of the secondary symp- 
toms, abscess (Fig. 712) 
possesses special interest 
because of the liability of 
the exudate to gravitate 
to a distant point. Par- 
alysis is usually a late 
symptom and is gradual 
in its onset, unless a 
pathological fracture or 
dislocation occurs, when 
it may appear suddenly. 
It is the result of various 
causes. Of these, com- 
pression of the cord from 
narroiving of the spinal 
column is rarest. The 
pressure of epidural 
exudate and peripachymeningeal granulations and the accumulation 
of pus is more common. Circulatory stasis and the formation of 
thrombi is not rare. According to Lange,^ local anemia ami edema, 
due to the circulatory disturbances coincident to the malposition 
of the muscles and bones (in kyphos), may cause motor and 
sensors- paralyses in restricted zones. In addition to this (in some 
instances), a certain area of the medulla of the cord may degenerate, 
and this, in turn, may be followed by ascending or descending degen- 
eration (gliosis) of its columns. Early relief of pressure (mechanical 
correction of malposition, aspiration, or laminectomy) is followed by 
return of function unless sclerosis has occurred. 




Fig. 712. 



Preparation of Double Psoas 
Abscess. 



The needle has punctured the cavity on the 
left side above Poupart 's ligament. 



1436 REGIONAL SURGERY OF THE SPINE 

In the lumbar region the deformity is usually that of lordosis, i. e., 
a prominent abdomen, a hollow back. Spasm of the psoas muscle is 
an early symptom. Fain radiates over the inguinal region and down 
the thighs. In ahscess formation, the exudate may gravitate to the 
pelvis (pelvic abscess) or a typical psoas abscess may occur. In the 
latter, the exudate makes its appearance just above Poupart's ligament 
(Fig. 712). 

In the thoracic spine the deformity varies from so-called ''round 
shoulders" to a v\;ell marked kyphos (Fig. 711). Pain is referred to 
the abdomen and radiates over the sides of the thorax; it is often spas- 
modic in character and is attended with labored respiration and cough. 
In abscess formation the exudate may appear between the ribs or 
posteriorly beside the spinous processes. 

In the upper region of the spine, which includes the cervical and 
upper two dorsal vertebrae, the attitude of the patient is character- 
istic; the head is held rigid and the eyes follow moving objects; the 
chin is often held by the hands. These symptoms are especially marked 
when the lesion is high up. Pain is referred to the ears and pharynx. 
In the lower segment of this region pain is referred to the neck, the 
sternal region,, and down the arms. In abscess formation the exudate 
gravitates to the pharynx and to the neck, where it appears in front 
of (rare) or behind (common) the sternomastoid muscle; it may 
appear over the posterior aspect of the vertebrae. 

The diagnosis in general is based on the regional symptoms stated 
and on the faulty alignment of the spine as a whole. To determine the 
character of the process, the history of the case, the development of the 
clinical picture in connection with other possible causative processes, 
such as pneumonitis, typhus abdominalis, lues, that omnipresent tuber- 
culosis, rheumatism, gonorrhea, etc., the acuteness or clironicity of the 
process, the Rontgenogram, and the examination of the cerebrospinal 
fluid must be taken into account. However, the reader is again re- 
minded that the process is not always tuberculous, despite the evidence 
of tuberculosis elsewhere in the body. The serological examinations 
(lues, gonorrhea, etc.) should not be omitted. Of course a patient 
with lues may develop a tuberculous spondylitis. 

The Rontgenogram is of great diagnostic value; however, the nega- 
tive must be properly interpreted, which is not always easy, especially 
with regard to the character of the lesion. Fig. 713 shows a Rontgen- 
ogram of a case of tuberculous spondylitis in the lumbar region. The 
Rontgenogram ir; also of value in recognizing the presence of gravita- 



SPONDYLITIS 



1437 



Hon abscesses. In some instauees it will reveal the presence of the 
thickened pyogenic membrane, and, when a fistulous tract is present, 
this is made visible by the injection into it of Beck's^ bismuth paste. 

When the presence of purulent exudate in the tissues surrounding 
the spinal column is suspected, the employment of the aspirating 
needle for diagnostic purposes is justifiable. The possibilities in this 
connection do not seem to be sufficiently strongl}- emphasized, not alone 
as to diagnosis, but also with respect to measures of relief. For the 

purpose, the aspirator shown 
in Fig. 364 or a large sized 
suction syringe connected with 
a hollow needle may be used. 

The treatment of spondylitis 
is based on the principles laid 
down in the discussion of in- 
flammatory lesions of bones 
and joints (Part IV, chap. iv). 
I a acute inflammatory processes 
the logical procedure would be 
to expose the lesion and excise 
or drain it in the same way as 
in acute osteomyelitis o r 
arthritis elsewhere in the body. 
I'nfortunately the location of 
the process makes direct attack 
Fig. 713.— Fistulous Tract Connecting a difficult problem. However, 
WITH Lumbar Spondylitis Made Visible jt Jg fair to assume that, as our 
IN the EoxTGENOGRAM BY Injecting Bis- ,, -, n -,• • i 

muth (Lange). methods oi diagnosis become 

more dependable, or, it may be 
said, as those we possess are more widely employed, it will become 
feasible to expose the lesion early in the disease and to apply direct 
measures of relief. In eases of tuhcrcidous spondylitis with paralysis 
decompressive laminectomy has been followed by excellent results 
(p. 1472). 

Wheii the presence of pus is established, it should be drained as early, 
and as near the seat of the lesion, as possible, with the view of obviat- 
ing gravitation of the products of inflammation to a distant point 
and secondary invasion en route. 

The general treatment of spondylitis is important. Since in most 
instances the lesion is tuberculous, the general treatment is similar to 




1438 



REGIONAL SURGERY OF THE SPINE 



that employed in combating this disease in other portions of the body. 
It must be remembered that iu not a few of the cases the lesion is 
luetic, gonorrheal, rheumatic, etc. 

Just as in bone and joint lesions elsewhere in the body, the mechan- 
ical treatment of spandijUtis aims at immobilization of the afflicted 




Fig. 714. 



Bradford and Lovett's Bed Frame for Horizontal Imjidblization 
IN Cases of Spondylitis (Whitman). 



part in such a manner that healing may take place with a minimum 
of deformity and permanent impairment of function. For the pur- 
pose, apparatus of various kinds are emploj^ed. These must of neces- 
sity vary in construction in accord with that portion of the vertebral 
column involved, the aim being fixation in a position in which the 
strain of use and the pressure of the superincumbent weight of the 




Fig. 71-5. — Modification of Frame Shown in Fig. 714. 
Traction applied to the head and limbs (Whitman). 

body are obviated. Of the various means for accomplishing this pur- 
pose, placing the patient in horizontal fixation is the most effective. 

Horizontal fixation apparatus has been devised b}" a number of sur- 
geons (Lorenz,^ Phelps,-* Redard,^ Whitman^ and others.) Wliitman,® 
whose experience in this connection is considerable, states that the bed 



SPONDYLITIS 



1439 



frame of Bradford and Lovett quite meets the requirements. This is 
a rectan^ihu- frame of gas pipe, a few inches longer and slightly 
wider than the patient's body. Covers of strong canvas are drawn 
tightly over the frame by means of corset lacings or straps on its under 

surface, leaving an 
interval beneath the 
buttocks for the u.se 
of the bedpan (Fig. 
714) . The frame may 
be bent to suit various 
])o.stures and counter 
extension is easily 
employed in connec- 
tion with it (Fig. 
715), Apparatus of 
this sort is used in 
spondylitis in all 
stages in young chil- 
dren and, in older 
children, during the 
acute stage of the 
disease. When the 
acute symptoms have 
subsided, ambulatory 
supports may be em- 
ployed; these consist 
of the gypsum jacket 
and the steel hrace. 

The GYPSUM JACKET 

is applied so that it 

SUPPORTS THE SPINE 
BY HOLDING IT IN THE 
ERECT OR EXTENDED 
POSITION, THUS TRANS- 
FERRING THE "WEIGHT 
IN PART FROM THE DISEASED VERTEBRAL BODIES TO THE LATERAL AND 

POSTERIOR PORTION OF THE COLUMN (Whitman^). The efficacy of 
the jacket depends upon the accuracy of its adjustment and upon 
the leverage it exerts above and below the site of the lesion. A 
tri-cot shirt reaching to below the knees is first applied to the body. A 




Fig. 716. — Suspension' Apparatus for Applying 
Gypsum. 



1440 



REGIONAL SURGERY OF THE SPINE 



band of china silk or linen about three inches in width is placed 
beneath the shirt on the back and front. These bands, which Lorenz^ 
calls "seratchers," may be manipulated beneath the jacket and keep 
the skin clean. The patient is then placed upon a stool and the halter 
of the suspension apparatus (Fig. 716) is adjusted, the arms are 
extended over the head, and the 
hands clasp the straps or rings. 
Sufficient tension is made upon the 
rope partially to suspend the body 
and to overcome the deformity as 
far as is practicable. The act of 
suspension should not cause pain 
(Sayre"). Before applying the 
gypsum, pads of felt or similar 
material are placed over the bony 
protuberances (anteriorspines, ster- 
num, etc.), and, finally, great care 
should be taken to pad thickly the 
surfaces immediatelj' contiguous to 
the seat, of the disease. In the 
female, the breasts (when present) 
are also protected. In very thin 
children, a pad is placed over the 
abdomen to allow for physiological 
increase in size in this situation. 
The gi/psmn handage, which should 
consist of wide meshed crinoline 
(not gauze), into the meshes of 
which gypsum hasbeen incorporated 
(by hand), is now molded in place. 
For the purpose, one person sits be- 
hind the patient and one in front, 
while the third may hold the guy 
ropes and control the tension and 
the position of the body. When the 

jacket is nearly firm, it is trimmed. As a rule, the apparatus should 
reach from the upper margin of the sternum to the pubes in front; 
behind, from about the middle of the scapula to the gluteal fold; 
laterally, it should be cut away .sufficiently to prevent chafing of the 
axilla above and below, on either side of the pubes, and an oval section 




Tig. 717. — The "T'at.ot .lArKKT," 
'Showing the Gypsum Applied 
TO THE Neck and Shoulders 
(Whitman), 



SPONDYLITIS 



1441 



is excised to allow of comfortable tiexioii of the thighs. After the 
jacket is applied, the patient is kept in the recumbent position until 
the gypsum is quite hard (at least half an hour). The skirt of the 
shirt is then folded over the jacket and sewed to the protruding buried 
portion. 

// the lesion is above the tenth thoracic vertebra, the gj'psum is car- 
ried about the neck and in front of the slioulders (Fig. 717). In 

many instances, and 
always in disease of 
the cervical region, 
support of the head is 
necessary. For the 
purpose, the head may 
be included in the gyp- 
sum dressing or a so- 
called "jury mast" 
may be employed. This 
consists of a strong 
steel brace, the bottom 
of which is incorpo- 
rated into the jacket 
helow the seat of the 
disease (Fig. 718). 

The essentials of the 
Calot jacket (Fig. 717) 
are fixation of the neck 
and shoulders as well 
as the pelvis, and di- 
rect pressure over the 
k3-phos, the front of the 
jacket being cut away 
so that the trunk may 
be forced forward, thus straightening the spine as a whole and, to a 
certain degree, correcting the deformity at the seat of the lesion. In 
applying the apparatus, the patient is suspended as stated. If the 
head is to be included, a special sling is used. The molding of the 
gypsum is also performed as stated. After the front of the chest and 
abdomen are covered with a one inch layer of cotton batting, the arms 
are supported at right angles to the body. The gypsum is applied 
very thickly. When the jacket is sufficiently firm, the patient is 




Fig. 718. — The "Jury Mast" Together with 
THE Ordinary Gypsum Jacket (Whitman). 



1442 



REGIONAL SURGERY OF THE SPINE 



placed on liis back and a small opening cut over the chest, through 
which the thoracic pad is removed, so that respiration may not be 
interfered with. The following day the front of the apparatus is cut 
away as shown in Figure 717. Another opening is made behind, ex- 
posing the scat of the disease; thi^ough this the skin is anointed and 
pads of cotton are forced into the opening to the point of tolerance, 
with the aim of pressing the trunk forward and of obliterating the 
kjTphos. The pads are held in situ by a few turns of a gj'psum band- 
age or by adhesive plaster. At intervals of several weeks, the pads 




Fig. 719. — Correction of a Kyphos with Pelotte and Screw. 



are changed, increasing, as far as possible, the pressure, with the 
view of still more obliterating the k^-phos. 

It is not infrequently necessary to apphj ike gupsum apparatus with 
the patient in the recumbent position, with or without traction. For 
the purpose a number of methods are en vogue, among which may be 
mentioned those of Taylor, Goldthwait and Metzger (see Whitman®), 
and the Hawley table. The Bradford-Lovett frame (Fig. 714) will 
be found \Qrj satisfactory for the purpose. The jacket may be worn 
for months (six) at a time; as a rule, it is necessary to replace it 
every two months. 

In Europe, Gaugerle's^ method of applying gypsum is largely used. 
The patient is postured on a specially constructed apparatus (Fig. 
719), which is fitted with a pelotte and screw. By means of the latter, 
the kjT^hos is gradually corrected (without narcosis) and the gj^Dsum 



SPONDYLITIS 



1443 



apparatus applied. Gaugea-lc^ reports ten cases of deformity with 
paraplegia in wliieh lie obtained favorable results. 

When the stage of recovery is reached, a gypsum corset ma}' be 
worn. This is simplj' a removable gypsum jacket, which allows of 
intermittant use under the guidance of the surgeon. 

Steel braces are the outcome of an effort to replace the gypsum . 
jacket with "something different." Much ingenuity, and more liter- 
ary and vocal efforts, have been expended 
in connection with their construction. 
They are not considered as taking the 
place of the gypsum apparatus in any 
regard. However, the one which has 
maintained a place in the textbooks for 
many years is that of Taylor (see Whit- 
man," who depicts several others) which 
is shown in Figure 720. 

The operative fixation of diseased ver- 
i tehrae, with the view of obviating the 
\ occurrence of kyplios, was first attempted 
by Lange^ (1899), who fastened the con- 
tiguous spinous processes to each other 
by means of paraffin oxycyanid silk. 
Bradford^" used bone plates in a similar 
manner. Hibbs^^ attempted to ankylose 
the vertebral arches by chiseling through 
the upper half of the spinous process 
and turning the fragment down, so that 
its point rested in a previously pre- 
pared groove of the next lower process. 
Bayer^^ regards the latter method as 
more desirable than the use of wires 
and other pliable materials. The technic 
of Albee^^ seems to overcome the objections raised in connection 
with the others. It is performed as follows: An incision is made, 
starting well above the lesion and curving to one side of the median 
line and carried back to the middle, well below the diseased area, thus 
forming a crescentic skin flap. Having dissected up the skin flap, the 
tops of the spinous processes and the supraspinous ligaments are 
exposed. The latter are split over the tops of the spinous processes, 
dividing them into equal halves ; the interspinous ligaments are also 




Fig. 



720. — The Taylor Back 
Brace (Whitman). 



1444 



REGIONAL SURGERY OF THE SPINE 




Fig. 721. — The Flexible Probe Bent to Conform to the Kyphos. 



To be used as a pattern in removing the curved graft from the anterolateral 
aspect of the tibia (Albee). 



split, care being- taken not to damage additional muscles and ligamen- 
tous attachments to those processes. Then, with a thin, sharp osteo- 
tome, the spinous processes are split (vertically) to a depth of 
from one third to two thirds of an inch. One half of each process 





Fig. 722. — Drawing of Cross Section of Tibia and Tibial Gr^vfts in Place. 

A is spinal graft for an early case that has not become kyphotic. B is cross 
section of graft which, on account of the large size of the kyphosis, is bent over 
it. D represents the multiple saw cuts on the marrow side. 

A illustrates a cross section of a spinous process split in half and fractured at 
its base. The deep, thin graft in cross section luis boon removed from the crest 
of the tibia, having its periosteum attached to two sides. The side in contact 
with the unbroken half of the spinous process is the saw cut or the medullary 
surface of the graft. 

B illustrates a cross section of a spinous process which has been split, and one 
half has been set over to produce a gap sufficient to receive a broad graft removed 
from the antero-internal surface of the tibia, having periosteum on one surface 
only; the medullary surface of the graft lies nearest the base of the spinous 
process in the gap (redrawn from Albee 's Bone Graft Surgery). 



SPONDYLITIS 



1445 



(always on tlio same side) is completely fractured at its base and 
moved over a distance vaiying in accord with the thickness of the graft 
which is to be imphinled. The length and shape of the required graft 
is determined by calipers and a fiexihle'prohe is applied to the gutter 
bed. The shape of the graft is likely to be nearly that shown in 
Figure 721, Using the bent probe as a pattern, a graft conforming to 
it is cut from the tibia with the twin saws, as shown in connection with, 
the surgery of bones. The graft may be partially sectioned at inter- 

vals in order to con- 
form it to the kyphos. 
The graft is so placed 
that the narrow, or 
saw cut, surface will 
be in contact with the 
side of the gutter 
formed by the un- 
fractured halves of 
the spinous processes, 
and its periosteal sur- 
face makes contact 
with the opposite side 
of the gutter contain- 
ing the fractured 
halves of the spines. 
The graft is held in 
place by s e a'^ e r a 1 
deeph^ placed sutures. 
The skin wound is 
closed wdth silkworm 
gut. Figure 722 
shows the outline of a 
small and a large 
tibial graft; A- shows a cross section of a spinous process wdth a 
small graft and B shows a process with a large graft embedded. A 
Rontgenogram of a graft embedded in the process of the cer\ical 
vertebra is shown in Figure 723. The behavior of the graft and its 
influence on genesis of bone in this situation are similar to those taken 
up in connection with the discussion of the problem as a whole (Part 
IV, chap. vi). The advantage claimed for the method is that ank}^- 
losis of the healed process takes place with less deformity than obtains 




Fig. 723. — E5ntg^nogram of Bone Graft in Cervi- 
cal Eegion (from Albee 's Bone Graft Surgery) . 



1446 REGIONAL SURGERY OF THE SPINE 

when the spine is immobilized with mechanical appliances. Albee^^ 
advises that, following the operation, the patient be kept on a fracture 
bed for from five to six weeks, with no more restraint than that 
afforded by pinning about the thorax a towel, to which four strips of 
broad muslin bandage are attached. The restraining bandage strips 
are so placed as to prevent the patient from sitting up or rolling from 
side to side, and are usually necessary only with children. When the 
spine presents a marked kj^phosis, it is necessarj^ to apply thick pads 
on either side of the spine before placing the patient on his back; 
when the deformity is severe, the lateral position is best used. Active 
work is not permitted until the end of about six months. During this 
time it is not, as a rule, necessary for the patient to wear any appa- 
ratus ; however, in severe cases there is no objection to the employ- 
ment of a gypsum corset for a few months. 

As already stated, spondylitis is mostly tuberculous in character. 
The treatment when the disease is due to other causes does not differ 
from that described above. It is probable that no other form of the 
disease is likely to be as prolonged as the tuberculous. 

Distorsio articularis sacro-iliacae gives rise to radiating pain, which 
may be mistaken for that due to spondylitis. In many cases the pain 
involves the zone of distribution of the great sciatic nerve (Gold- 
thwait^*). In some of the cases the pain is relieved by a properly 
fitting support, although in not a few instances nothing seems to afford 
relief. No doubt the inaccessibility of the joint, which makes this a 
difficult problem, together with the uncertaint}^ of the diagnosis, has 
acted as a deterrent in this connection. Lovett and Reynolds^^ con- 
sider that pain in the sacro-iliac region is due (in some instances) to 
faulty carriage of the body, the result of gynecological conditions, and 
advise that these be remedied before the case is condemned to hope- 
lessness. 

A special form of spondylitis is described by Lange^ under the term 
chronic traumatic spondylitis. The disease occurs in adults following 
a severe injury. He likens the condition to that occurring (after 
injury) in the knee and ankle joints, in which the lesion is restricted 
to pathological processes in the periosteum and ligaments. In a cer- 
tain number of cases, the disease is an already existing mild spondy- 
litis deformans (whatever that may mean), which is simply accentu- 
ated by the injury ; it usually occurs in elderly persons. 

Bechterew and StrlimpeP'' describe a condition of the spinal column 
which they designate as chronic verteiral ankylosis. It appears in 



SPONDYLITIS 1447 

the literature as spondijUtis, and spondijlarthritis ankylopoetica, and 
spundijlusc rhizoincUqiie (Pierre Marie^'). llistologically, the disease 
does not differ from the picture presented in connection with chronic 
inflammatory processes involving* bones and joints in general. That 
is, we probably are not confronted with a clinical, nor, indeed, a patho- 
logical entit}', but with the result of syphilis, rheumatism, gonorrhea, 
influenza, etc. If this is true, then the discussion entered into above, 
as to the desirability of recognizing the character of the causative 
factor in spondylitis as a whole, is worth heeding. 

The condition is attended with pain, interference with functian, and 
defo-nnitij; the last often going on to kyphosis, especially in old per- 
sons. The muscles of the back of course atrophy. It is not at all 
improbable that the person "bowed by the cares of a long arduous 
life" is often afdicted with chronic spondylitis which had its origin in 
nothing more emotional than the colonization of the gonocQceus or the 
spirocheta pallida, and an early diagnosis and appropriate treatment 
might have arrested the progress of the disease. 

For rachitic spine see Rachitis, page 1074. 

For scoliosis see The Surgery of Deformities, Part VIII, chap, viii, 
p. 1370. 

BIBLIOGRAPHY 

1. Laxge. Lehrbueh. d. Orthop. Chir., Jena, 1914. 

2. Beck. Beitr. z. klin. Chir., Ixii, 1909. 

3. LOREXZ. Lehrbueh. d. Orthop. Chir., 3d. ed. 

4. Phelps. Tr. Amer. Orthop. Assoc, 1891, iv. 

5. Redard. Chir. Orthop., Paris. 

6. Whitman. Tr. Amer. Orthop. Assoc, 1901. 

7. Sayre. Quoted by Whitman No. 6. 

8. Gaugerle. Arch. f. klin. Chir., Bd. xc 

9. Lange. Wiener Klinik, 1899. 

10. Bradford. Quoted by Baj-er in No. 1. 

11. HiBBS. Anns. Surg., Maj^, 1912. 

12. Bayer. See Lange No. 1. 

13. Albee. Bone Graft Surg. Phila. and London, 1915, 

14. GoLDTHWAiT. See Lange No. 1. 

15. Lovett and Reyxolds. See Lange No. 1. 

16. Bechterew and Strtjmpel. See Lange No. 1. 

17. Pierre Marie. See Lange No. 1. 



CHAPTER IV 

INJUEIES OF THE SPINAL CORD 

Concussion of the Spinal Cord. — The question as to whether there is 
such a thing as pure concussion of the spine has been made the subject 
of much discussion. A reiteration at this time of the various views in 
this connection does not serve a useful purpose. Frazier^ summarizes 
the situation as follows: "When there is injury to the spinal 
column without a bony lesion but with subsequent alteration in 
the spinal cord, it were well to class such cases as contusion and to 
eliminate the term concussion as applied to the spinal cord altogether." 
On the other hand, there is a class of cases of injury of the spine, the 
pathological anatomy of which is not discoverable, that are described 
in the literature under the head of '^ railway spine." Irrespective of 
whether the condition is attended w^ith minute hemorrhages or is the 
outcome of commotion of the spinal cord or not, it certainly represents 
a clinical entity and may be described as such. 

Usually, the clinical history of ''railway spine" is that the patient 
in a railroad accident is thrown violently forward out of his seat and 
against the back of the seat in front, or, in cases of rear end collisions, 
he is subjected to a violent impact along the entire spinal column. 
Aside from the objective contusions, etc., there is always severe fright, 
and this must not be overlooked or belittled. The patient may be able 
to get up and walk to a place of safety after the accident, but the 
disturbaoice to his nervous system is very apparent and, though objec- 
tively uninjured, he feels weak and dizzy, and at times evinces great 
"emotionalism," weeping or laughing — possibly, both together. 
Often, though' helping to extricate his more unfortunate companions, 
he is greatly nauseated and vomits. 

From this on there are four possibilities. (1) He may rapidly 
become perfectly normal and show no ill effects from his experience; 
(2) he may exhibit signs of organic involvement of the spinal cord, 
which sjTnptoms may increase in severity as time goes on (traumatic 
spinal apoplexy) ; [manifestly, these two eventualities have nothing 

1448 



INJURIES OF THE SPINAL CORD 1449 

to do vvitli railway spine | (.'3) he may become the subject of traumatic 
neurasthenia; and (4) he may suffer from traumatic hysteria. The 
last two contingencies open a wide field, one wliich leads to a discus- 
sion far bcj'ond the possibilities of this book. Suffice to say that the 
disturbances following- the class of injur}- spoken of are real; that 
they are the outcome of a disturbed nerve function ; and that they 
present a complex symptomatology which includes modification of 
motion and sensation and inactivity of the viscera of tlie exhaustive 
type. 

Hysterical railway spine is a still more confusing problem than the 
so-called neurasthenic type. It is taken up in extcitso by Babinsky 
and Proment- in connection with war injuries. Their work also fur- 
nishes a complete bibliograph}' on the subject. 

Hematomyelia. — Ilematomyelia may be defined as a hemorrhage in 
the spinal cord following trauma to the spinal column, with or with- 
out a lesion of the spinal column. The mechanical explanation of its 
occurrence may be sought for in the fact that a shock is transmitted 
to an incompressible column of fluid contained in delicate elastic tubes 
which, particularly in the gray matter of the spinal cord, receive but 
meager support from the surrounding tissues. 

The effusion of hlood in hematomyelia varies in size from a small 
group of erythrocytes (microscopical) to a cavitj^ filled with blood 
occupying over one half the transverse diameter of the cord. The 
perpendicular extent of the bloody effusion may be restricted to one 
segment or may invade several of them. As a rule, the damage to the 
gray matter is the greater (Allen^). 

The symptoms of hematomyelia relate of course to- impairment of 
the function of the part dominated by the injured area. These do not 
differ in any regard from those attendant upon other lesions, except 
perhaps in the fact that, if ax appreciable period of time elapses 

BETWEEN INFLICTION OF THE TRAUMA AND»THE ONSET OF THE SYMPTOMS, 

THE PRESENCE OF HEMORRHAGE MAY BE ASSUMED. The Severity of the 
sjinptoms indicates the extent of the hemorrhage. A clinical working 
basis as to localization is presented farther on. 

The prognosis in uncomplicated cases, as far as life is concerned, 
is good. The period of absorption of the effusion of blood is very 
variable (six to ten months). Destroyed nerve cells are not regen- 
erated. 

The treatment aims at complete rest until the acute s^-mptoms sub- 



i450 REGIONAL SURGERY OF THE SPINE 

side. The distorting effect of the incompletely or completely paralyzed 
muscles must be obviated. Massage is useful in all cases. 

Contusion of the Spinal Cord. — The term contusion of the cord is 
applied to injuries in which there is no solution of continuity. Allen^ 
has shown that small impacts, sufficient to cause complete motor or 
sensory paralysis, with initial loss of all reflex activity below the level 
of the injury, may not be inconsonant with complete recovery. As a 
rule, CONTUSION of the cord is the most important factor in frac- 
ture OR dislocation of the vertebrae ; it may, however, occur with- 
out either of them. 

Laceration of the Spinal Cord. — The cord may be lacerated by gun- 
shot projectiles; or the laceration may be incidental to a stab wound, 
or to a fracture or dislocation of the vertebrae. In the last instance, 
the osseous displacement is greater than in contusion. The laceration 
of course varies in degree and is attended with a clinical picture in 
this proportion. In slight lacerations, the prognosis, as regards life, 
is not bad ;• when the cord is completely torn, a fatal outcome usually 
supervenes in a short time. In a general way, it may be said that 
the higher the injury, the graver the prognosis. 

An exact diagnosis as to the degree of laceration is not always pos- 
sible, as, especially in gunshot wounds, contusion and laceration 
coexist. In gunshot wounds impact of the projectile may severely 
contuse the cord without perforating the dura. Particularly interest- 
ing experimental work has been done in this connection by Allen.^ 

The Symptomology of Complete and Partial Cord Lesions. — It may be 
said that the symptomologj' of cord lesions is dependent upon the 
extent of destruction of tissue, irrespective of the character of the 
causation, and therefore, for convenience, is discussed under one head. 
In studying this somewhat complex problem, it is desirable to bear in 
mind that the earlier a clear conception of the motor and sensory 

SYMPTOMS IS recorded, THE^ MORE READILY IS A CONCLUSION POSSIBLE 
AS TO THE ADVISABILITY OF MAKING OPERATIVE EFFORTS AT RELIEF. 

The sjonptoms bearing on the question as to whether the lesion is a 
complete or an incomplete (or partial) one are formulated by 
Frazier^ as follows : 



INJURIES OP THE SPINAL CORD 



1451 



COMPLKTE 



PARTIAL 



Usually llaci'idity of all muscle 
groui»s whose iiiiiervatiou comes from 
segments below tiie level of the lesion. 
Paialysis is complete. 



Loss of reflexes whose arcs lie in 
segments below the level of the lesion. 



Complete loss of control of bladder 
and rectum, which is demonstrated by 
either constant dribbling or by peri- 
odic evacuation without knowledge or 
volition. 

Complete loss of all forms of sensa- 
tion of a sharp segmental distribu- 
tion. 



The sjTnptom picture is stationary 
with a tendency toward trophic 
changes for the worse. 



A si)astic condition with or with- 
out contractures of muscle groups 
whose nerve supply comes from 
segments below the level of the lesion. 
Paralysis may not be total. 

Increase of reflexes whose arcs lie 
in segments below .the level of the 
lesion! Presence of the Babinsky 
phenomenon. 

A joossible i:)artial control of blad- 
der and rectum, with at times knowl- 
edge on part of patient that evacu- 
ation is taking place. 



Loss of sensation is not absolute, 
in that the patient often perceives 
strong stimuli of protopathic nature, 
and is at times able to detect changes 
in position. 

The symptom picture is not neces- 
sarily stationary, and a gradual im- 
provement may be noted. 



It remains to consider the symptoms irhich indicate the level of the 
lesion. 

In lesions of the fourth cervical region the motor sym^ptoms are 
those of a complete quadriplegia. As the main origin of the phrenic 
nerve lies in the fourth cervical segment, there will be total paralysis 
of the diaphragm, and breathing will be costal in type. The sensory 
symptoms will be complete loss of all forms of sensation up to and 
including the skin area supplied by the fourth cervical vertebra (Fig. 
724). In transverse lesions in the cervical region it must be remem- 
bered that the fibers from the midbrain to the celiospinal center in the 
eighth cervical and the first thoracic segments are sectioned and that, 
although the celiospinal reflex shares to a certain extent the automatic 
action of the other autonomic mechanisms, in the cases of high cervical 
lesions we are likely to have bilateral contracted pupils. 

In lesions of the fifth cervical segment the symptoms are practically 
the same as when the fourth segment is involved, with the exception 



1452 



REGIONAL SURGERY OF THE SPINE 



that the major part of the phrenic nerve escapes, and. therefore the 
diaphragm is not paralyzed. 

In lesions involving the sixth cervical segment, the upper root of 
ike brachial plexus escapes, and consequently partial preservation of 
the power in the shoulder girdle obtains. In other respects the clinical 
picture is the same, except that tactile sense is preserved on the upper 
and outer surface of both arms. 




Fig. 724. — Sensory Disturbances Followixg ax Injury of the Fourth 
Cervical Segment (Frazier). 



In lesions involving the seventh cervical segment, the biceps tendon 
reflex is preserved. This is at times exaggerated. The patient is verj' 
likely to assume the position shown in Figure 725. The sensory dis- 
turbances are peculiarly significant and are .shown in Figure 726. In 
cases of injury it is necessarj^ to bear in mind that effusion of blood 
may provoke the appearance of sjinptoms emanating from the segment 
above. 



INJURIES OF THE SPINAL CORD 



1453 



In lesians involving the ninth thoracic segment there is of course no 
paralysis of the upper extremities. However, there is complete paraly- 
sis of the lower extremities which, as in injuries of higher levels, is 

either flaccid or spas- 
tic. The semsor y 
symptoms are as men- 
tioned above (Fig. 
727). 

In the lesions al- 
read}^ recorded, the 
bladder and rectum 
symptoms are very 
similar. As the path- 
ways of sensory con- 
duction from bladder 
and rectum are inter- 
rupted, the patient 
does not feel disten- 
tion of either. At 
first (the reflex activ- 
it}' being set aside) 
there is a tendency to 
the incontinence of 
retained material 
after a certain 
amount of accumula- 
tion of excretion has 
occurred. 

Ill lesions of the 
second and third lum- 
har segments the 
motor picture is one 




Fig. 725. — Position of the Upper Extremities in a 
Complete Tkan-svekse Lesion of the Cord at the 
Level of the Seventh Cervical Segment (Fra- 
zier). 



of complete paraplegia, which is likely to be of the flaccid type. 
The sensory disturhance is limited to a line corresponding to 
Poupart's ligament (Fig. 728). As the centers of micturition and 
defecation are located in the first and second lumbar and the second 
and third sacral segments, the disturblances of urination and defeca- 
tion are very serious. 

The Broicn-Se guard syndrome is present in lesions involving more 
or less definitely one half of the cord. The symptoms presented by 



1454 



REGIONAL SURGERY OF THE SPINE 



such a lesion in the fifth or sixth thoracic segment would be as fol- 
lows : Complete parah'sis of the right lower extremity — most likely 
of the flaccid type ; some diminution or loss of tactile sensation on 
the right, extending up on the trunk to the cutaneous distribution of 
the fifth thoracic nerves (this tactile anesthesia will be neither pro- 
found nor permanent) ; a loss of pressure, position, and osseous sense 
on the right below the level of the lesion ; loss of thermal and pain 




Fig. 



726. — Sensory Disturbances Following a Lesion of the Seventh 
Cervical Segment (Frazier). 



sense on the left up to a line somewhat lower than the sensory involve- 
ment on the opposite side. In addition to this, there are certain sensory 
disturbances forming a zone of variable width between the normally 
innervated skin above and the anesthetic areas below (Fig. 729). 

Lesions of the Cauda Equina. — In lesions below the second lumbar 
vertebra the substance of the spinal cord is not involved, as this struc- 
ture ends at about the disc between the first and second lumbar ver- 



INJURIES OF THE SPINAL CORD 



1455 



tebrae. However, here the spinal nerves form a great collection, en- 
circling the conus and running down the canal to their points of 
exit. It follows, then, that a lesion in this situation, in accord with 
its exact location, may involve all or only a part of these conducting 
elements, and that the motor and sensory symptoms would correspond 
to the seat of the involvement. A lesion located between the second 
and third lumbar vertebrae is characterized by involvement of the 




Fig. 727. — Sensoky Disturbances Following an Injury of the Ninth 
Thoracic Segment (Frazier). 



entire lumbosacral plexus and by paralysis of the bladder and rectum. 
Sensation is lost below Poupart's ligament. If the lesion is below 
the fifth lumbar nerve, the motor disturbances are restricted to the 
lower legs and feet, and sensation on the dorsum and. sole of the foot 
and a strip on the back of the leg is impaired or lost. 

The treatment of lesions of the spinal cord, other than the general 
care of the patient, already discussed in connection with fractures 



1456 



KEGIONAL SURGERY OF THE SPINE 



(Part IV, chap. \), relates to the question of operative measures of 
relief. In cases of injury, as already stated, this is not easily decided. 
In arriving at a conclusion, the surgeon must make a careful study 
of the sequence of symptoms as they develop from the time the injury 




Fig. 728. — Sensory Distukbaxces Following an Injiey of the Second and 
Thikd Lumbar Segments (Frazier). 

was received and interpret them as balanced against the actual physical 
possibilities connected with his available measures of relief which, 
after all, consist simply in the removal of compressing agents, i. e., 
foreign body, bone, blood and exudate. If, therefore, an intensive 
study of the case indicates that the attempt to remove the otfending 
agent is justified, he may, with a clear conscience, proceed to operate. 
It is here reiterated, that surgical repair of divided or destroyed nerve 
centers is not followed by regeneration. For the technic of the ex- 
posure of the spinal canal see Laminectomy (p. 1472). 



INJURIES OF THE SPINAL CORD 



1457 



Stab and Gunshot Wounds of the Spine and Contents of the Spinal 
Canal. — The disti)iclivc clinical faclor in stab and gunshot wounds 
of the spine relates to ixjiir!/ of the cord and its membranes, of which 
of course the former is the more important. Therefore, the subject is 
taken up at this time. 

Stab Wounds. — Stab wounds arc inflicted by sharp or pointed in- 




FiG. 729. — Brown-Sequard Syndrome in Lesion of the Sixth Thoracic 

Segment. 

On both sides below the cutaneous distribution of T5 there may be ill defined 
areas of tactile anesthesia (Frazier). 

struments, such as a sword or a knife. Of 93 cases collected b.v Petren/ 
43 were in the cervical and 50 in the thoracic region. The osseous in- 
jurj'- does not present any peculiar surgical prohlem; the importance 
of the lesion relates to contusion and puncture of the membranes and 
to involvement of the cord, which may be a complete section. As a 
rule, the instrument enters the canal between the arches of the verte- 



1458 REGIONAL SURGERY OF THE SPINE 

brae ; however, it occasionally happens that an arch or a spinous 
procss is fractured. Not infrequently, a portion of the instrument is 
left in the vertebra, sometimes partially in the canal. 

Extradural hemorrhage is usually insignificant. Occassionally, there 
is a cerebrospinal fistula with free escape of the fluid, which presents 
great danger of infection. The fact that cerebrospinal fluid does not 
escape from the wound does not exclude the possibility of penetration 
of the dura. On the other hand, the cord may be severely contused and 
the dura remain intact. 

The symptoms, when the canal is penetrated and the cord injured, 
are those of immediate paralysis. These vary in accord with the loca- 
tion of the trauma and do not differ from those following other in- 
juries. After a short time the Brown-Sequard syndrome is very 
likely to make its appearance. This is very easy to understand 
from the nature of the injury (Rauzier and Rimbaud^). 

The treatment of stah wounds of the spinal contents must take into 
consideration the wound, the presence of a foreign body, a cerebro- 
spinal fistula and injury to the cord. The majority of these wounds 
are not infected and must simply he kept clean. Prohing is not per- 
missible; a Rontgenogram must be taken at once to determine the 
presence of a foreign body and its location. 

Operative measures are indicated (see Laminectomy, p. 1472) when 
the Rontgenogram reveals the presence of a portion of the instrument 
in contact with the membranes or the cord. In the absence of this 
guide, evidence of pressure on the cord may be regarded as an indica- 
tion to operate. The general care of the patient is important (see 
Fractures, etc., of the Spine, Part IV, chap. v). 

Gunshot Wounds.- — Gunshot wounds of the spine and spinal cord 
are among the most serious of war injuries. The^^ occur at every 
level, although they are most frequent in the thoracic region. Statis- 
tical analyses in this connection are furnished by Exner," Prewitt,'^ 
and Haynes and Moorhead.® 

The ho7ie lesions depend upon the portion of the vertebra involved 
and upon the character of the projectile. The arches and spinous pro- 
cesses are more often fractured than the bodies. 

The cord lesions are of course the important factors in this class of 
injury. The cord may be severely lacerated or even completely 
severed by direct contact with the bullet or by pieces of bone driven 
into it by the projectile; it may be compressed by displaced fragments 
of bone, by the bullet protruding into the canal, by a subdural hemor- 



INJURIES OF THE SPINAL CORD 



1459 



rhage, or by adhesions or serous exudates ; it may be contused by the 
bullet and splinters of bone ; and, finally, the cord may undergo struc- 
tural changes from the effects of concussion or commotion caused 
by the impact of a projectile striking against some portion of the 
vertebral column and bounding back to become lodged in the soft 
parts; or the sudden atmospheric changes caused by the explosion of 
shells in the vicinity of the patient may result in changes in the spinal 

cord. Jumentie" reports a 
case of indirect injury of 
the cord at some length ; 
its history is repeated by 
Frazier.^ 

Laceration and contusion 
of the cord by a projectile 
does not differ from that 
produced by other agents, 
except that they are likely 
to be very severe. 

Compression of the cord 
hy a projectile produces, 
first, irritation, and later, 
pressure. If the pressure 
is not promptly removed, 
edema, myelitis, and, 
finally, necrosis and other 
grave degenerative changes 
take place. In no case is it 
permissiMe to allow the 
bullet to remain in situ; 
sooner or later, it will give 
rise to inflammatory exud- 
ates, adhesions, and thick- 
ening of the dura, which eventually extend to the cord. Bullets give 
rise to extensive hematomyelia. 

In some cases the disturbances caused by the bullet are attended 
with adhesions of the leptomeninges and collections of fluid, presenting 
a picture of serous meniyigitis. The collection of fluid causes pressure 
symptoms, which demand early intervention. 

Concussion of the cord in connection with bullet wounds of the spine, 
in which there is no bone lesion or only an insignficant one, has been 




Fig. 730. — X-Hay Showing Bullet be- 
tween Second and Third Cervical Ver- 
tebra, IN A Vertical Plane Correspond- 
ing to the Eegion of the Spinal Cord 
(after Perthes). 

The position of the bullet corresponds to 
the level of the cord lesion (Frazier). 



1460 REGIONAL SURGERY OF THE SPINE 

carefully studied during the ' ' World War. ' ' In most of these eases, 
the projectile has struck the vertebral column and rebounded to be- 
come embedded in the soft tissue, or in an organ more or loss remote 
from the spine, but the impact of the bullet is so great that the vibra- 
tory force is transmitted to the cord, resulting in medullary lesiotis 
varying from slight degrees of contusion to complete disintegration. 
Many theories have been advanced as to the cause of these changes. 
These comprise the possibility of a momentary displacement of the ver- 
tebrae (temporary subluxation) and the belief that the cord is caused to 
oscillate within the canal (Fickler"). Frazier^ regards the latter as 
a reasonable explanation. Claude and L'Hermite^^ suggest that the 
shock transmitted to the cerebrospinal fluid and the temporary in- 
crease in pressure bring about an ischemia sufficient to cause insula- 
tory necrosis of the marginal vessels. This theory would seem to be 
supported by a case reported by Latarjet^^ and published in English 
by Frazier.^ Mussen, also quoted b.y Frazier,^ reports the histological 
findings in a case of this sort. The lesions consist in hematomyelia, 
edema, myelomalacia, disseminating myelitis, acute traumatic necrosis, 
hematorrachis, and arachnitis serofibrosa spinalis (see also Oppen- 
heim^'^). It also not infrequently happens that these cases develop 
changes in the meninges and abnormal collections of fluids. The cir- 
cumscribed form of serous meningitis has been studied by Marburg^* 
and Rumpf .^^ 

The symptom complex following gunshot wounds of the spine and 
cord does not differ materially from that attendant upon other in- 
juries. Pain, the result of irritation of the spinal roots, is likely to be 
severe. For the purpose of localizing the cord injury see page 1450. 

In the diagnosis, the Rontgenogram is of great assistance, especially 
in determining the question of whether the cord is invaded by the pro- 
jectile or by splinters of the bone. 

The operative treatment is determined by a judicious consideration 
of all the factors. In indirect injuries, early operation is c(yntraindi- 
cated. If evidence of increasing pressure (from blood or exudate) 
develops, the canal may be opened. In direct injuries, the propriety 
of laminectomy is established (Frazier^) ; this view is strongly sup- 
ported by Oppenheim.^^ The operation should be performed as soon 
as the shock of the injury subsides (see Laminectomy, p. 1472). For 
additional literature see bibliography of Frazier.* 



INJURIES OF THE SPINAL CORD 1461 

BIBLIOGRAPHY 

1. Frazieb. Surgery of Spine and Spinal Cord, N. Y., London, 1918. 

2. Babinsky et Fuoment. Med. et Surg. Tlierap., ii, 1918, with lit. 

3. Allen, Quoted by Prazier No. 1. 

4. Petken. Arch. f. Psychiat., Berlin, 1910, xlvii. 

5. Rauziek et Rimbauu. Rev. neurol., Paris, 1909, xvii. 
G. Exner. Neue Deutsch. Cliir. Tiibingen, 1915, xiv. 

7. Prewitt. Anns. Surg., 1898, xxviii. 

8. Haynes and Moor head. N. Y. Med. Jr., 1900, Ixxxiv. 

9. JuMENTiE. Rev. neurol., Paris, 1914-1915, xxviii. 

10. FiCKLER. Quoted by Frazier No. 1. 

11. Claude et L'Hermite. Ann. d. med., Paris, 1914, ii. 

12. Latarjet. Lyon chir., 1916, xiii. 

13. Oppenheim. Berlin klin. Woch., 1914 

14. Marburg. Neurol Centrbl., 1915, xxxiv. 

15. RuMPF. Med. klinik., 1915, xi. 



CHAPTER Y 

SPINAL TUMOES 

Although, tumors of the spinal cord, of the meninges and of the 
vertebral column are still regarded as rare, it is not improbable that 
inadequate diagnostic measures are to a considerable degree responsible 
for this conception. However, the progress in this connection since 
Horsley reported the first removal of a spinal tumor (1887) is very 
encouraging. This is to no little extent due to the researches of 
Dejerine,^ Sherrington,- Head," and others. Frazier,* in a search of 
the literature, found 330 cases of tumors in which operations had been 
performed. Of these, 152 were meningeal, 58 vertebral, 36 intramedul- 
lary, 30 caudal and o4c in which the origin was not stated. 

The etiology of tumors of the spinal cord may be regarded as little 
understood, as is the case in tumors in general (see Tumors, Part VI). 

As to frequency of location, Frazier* presents a series of statistics. 
In one table (SchlesingerV) the interesting fact is recorded that of 
135 tumors of the spine 91 were vertebral in origin. 

Regarding the character of the tumors involving the spine, almost 
all classes of new growths are represented in the 330 cases collected 
by Frazier.* Excluding sarcoma, those belonging to the fibroblastoma 
class are the most frequently found; strange to say, only one was a 
gumma. Metastatic carcinoma and sarcoma of course make up a not 
inconsiderable proportion of the tumors in this situation. The former 
frequently occurs in connection with mammary carcinoma. A notion 
of the appearance of a spinal tumor in situ may be gathered from 
figure 731. 

The symptomatology of spinal tumors, whether extramedullar?' or 
intramedullary, is sooner or later manifested through involvement of 
the spinal nerve roots and their respective segments in the spinal cord. 
The damage they inflict upon the ti.ssues of the cord takes at first the 
form of irritation, then of compression, encroachm£nt , or destruction, 
depending upon the location and character of the growth. 

Frazier* describes three established cycles in the life history of the 
spinal tumor. The first, or root, cycle is the longest, and the symp- 
toms, usually unilateral in the early stages, are those of irritation, and, 

1462 



SPINAL TUMORS 



1463 



later, of eomprpssion. These are paresthesia, pain, hyperesthesia, and 
anestliesia in the areas innervated by tlie alVeeled posterior roots; also 




Fig. 731. — An Endothelioma Drawn in situ, before Its Eemoval from the 
Spinal Cord at the Level of the Third Cervical Vertebra (University Hos- 
pital). 

The tumor appeared to take its origin from the dura in the lateral aspect of 
the spinal canal (Frazier). 



tremors, muscular spasm and spasticities followed b}' muscular atrophy 
and paresis in the distribution of the involved anterior roots. As 
tumors are usually situated on the posterior surface, the motor symp- 



1464 REGIONAL SURGERY OF THE SPINE 

toms are less frequent than the sensor}-. The second cycle is that of the 
Brown-Sequard syndrome (Fig. 729). This cycle is almost constant, 
unless the tumor is intramedullary, Oppenheim'^ has known only one 
case of extramedullary tumor in which the third stage was not pre- 
ceded hy the Brown-Sequard syndrome. The third cycle is character- 
ized by weakness, and, later, by paralj'sis of the bladder and rectum, 
at first exaggerated, and, finally, by abolition of all reflexes whose 
arcs are involved and by vasomotor and trophic disturbances. Of the 
symptoms, constriction of girdle sensations are among the most dis- 
tressing and are likely to mislead the practitioner into directing 
efforts at relief to the parts to which the pain is referred, such as 
operative attack upon the stomach, the gallbladder, the kidney, and 
the urinary bladder. The motor and sensory sj'mptoms indicative of 
the location of the tumor are taken up on page 1450. However, the 
determination of the level at which a tumor is located is a problem of 
considerable magnitude; one which requires patient study and care- 
ful, thorough, frequentl}^ repeated examinations, by which the some- 
times very gradual progress of the lesion may be recognized. Aside 
from the usual so-called neurological examination, that of the spinal 
fluid (lumbar puncture, p. 1414) must not be omitted, especially with 
regard to lues. 

The treatment of spinal tumors is restricted to operative efforts at 
relief. Frazier* says "Excluding such lesions as tabes dorsalis or 
poliomyelitis, conditions usually clearly recognized and presenting 
no surgical indications, there remains a group of lesions of which 
tumors constitute a large proportion and in which the signs and symp- 
toms point to a distinctly localized lesion, that is either driving the 
patient to distraction through pain, or destroying the cord by pres- 
sure. " There are of course a number of cases in which the precise 
nature of the lesion, before operation, is impossible of recognition; 
nevertheless, exploratory operation should ie performed in all douht- 
ful cases. Exploratory laminectomy is 'of itself free from peculiar 
dangers; the time has passed when fear of opening and exploring 
the dural sac should be harbored. The earlier the operation, the better 
the outlook in every conceivable way. 

The indicatimis for operation may be summarized in a few words as 
being the recognition and localization of a lesion, the symptom 
complex of which indicates a new growth or even, with certain restric- 
tions, a chronic inflammatorj^ lesion in a patient whose condition is 
not prohibitive of any operative undertaking. The location of the 



SPINAL TUMOKS 1465 

lesion in the npper segments is not a contraindication, as tumors have 
been successively removed from the level of the axis vertebra. Nor is 
it justifiable to withhold operative measures because the lesion is 
believed to be intramedullary', as this belief is not always correct and 
also because even an intramedullary growth, may be favorably influ- 
enced by removal or by nerve decompression. The first intramedullary 
growth was removed by von Eiselsberg^ (1907), since when 36 cases 
have appeared in the literature (Frazier*). 

In secondary (metastatic) tumors, the decompressive operation is of 
value in a palliative sense, especially with regard to pain. The 
posterior roots may be divided at the same time. Laminectomy is 
described in chapter vii. (For additional literature see bibliography 
of Frazier*). 

BIBLIOGRAPHY 

1. Dejerixe. Semiologie des affect, du systeme nerveux, Paris, 1914. 

2. Sherrington. The Integ-rative Action of the Nervous System, London, 

1906. 

3. Head. On Disturbances of Sensation, etc., London, 1894. 

4. Frazier. Surgery of the Spine and Spinal Cord, N. Y. and London, 

1918. 

5. Schlesixger. Beitr. z. klinik der Riickenmarks and Wirbeltumorren, 

Jena, 1898. 

6. Oppenheim. Lehrb. d. Nervenkrank, Berlin, 1913; also, with Borehardt, 

Mitt. a. d. Grenzgeb. d. Med. u. Chir. Jena, 1913, xvi. 

7. V. EiSELSBERG. Arch. f. kHn. Chir., Berlin, 1913, cii. 



CHAPTER VI 

SURGEEY or THE SPINAL EOOTS 

The surgery of the spinal roots is still in its initial stage of develop- 
ment. However, the student should realize that the subject is full of 
possibilities, especially with regard to the relief of spasticity, which, 
when attained, is among the most gratifying in the practice of surgery. 
Following recognition of the importance of the posterior roots in the 
conduction of pain, the question of directly attacking them came 
under consideration, with the result that Abbe^ (1888) and Bennett^ 
in the same year divided these structures. Abbe's case was free from 
pain for two years. Bennett's case died from cerebral hemorrhage 
on the twelfth day following the operation. In 1908, Forster^ sug- 
gested that resection of the posterior roots be applied in severe forms 
of spasticity and described the technic Tietze* had worked out on the 
cadaver. Shortly after this Forster^ applied the method for the 
relief of gastric crises. 

Rhizotomy for the relief of pain has been employed in neuralgia of 
the upper and lower extremities, intercostal neuralgia, intractable pain 
in amputation stumps, neuritis of traumatic and luetic origin, pain due 
to herpes zoster and to pressure from inoperative sarcoma and carci- 
noma. The results of the operation for the relief of pain have not 
fulfilled the expectations of the inceptors of the operation; the pro- 
cedure has been found to be much more effective in the treatment of 
spasticity and visceral crises. This does not mean that pain has not 
been relieved; on the contrary, a number of cases are reported in 
which the patient was entirely relieved; but it does mean that the 
exact source of irritation was not located in all the cases, and that this 
must be established before operative measures of attack may be ex- 
pected to afford relief. The reports of cases include operations by 
Abbe,^ Chipault,® Jones,'' Mayo,^ Horsley,^ Giordani" and Hilde- 
brand." Of the cases operated upon for pain in amputation stumps, 
those analyzed by Knapp,^^ Bennett,^ and Kilvington^^ may be studied 
with advantage. 

1466 



SURGERY OF THE SPINAL ROOTS 1467 

Rhizoi 0)111/ for the rclirf of spasticity has been practiced most often 
in connection witli the various spastic affections of the central norvons 
system, spastic paraplegia and diplegia of congenital origin (Little's 
disease). Frazier" has collected seventy cases of Little's disease in 
which rhizotomy has been performed; two of which were practically 
cured, fifty-six were improved, three were unchanged, and nine died. 
In estimating these results, the factors adduced by Dejerine^^ may well 
be taken into account. Dejerine quite properly says that "Little's 
disease is not really a disease, but rather a syndrome and this makes 
an appropriate method of treatment very difficult." 

In the acquired forms of infantile spastic conditions, section of the 
posterior nerve roots is not as efiPective as in the congenital types. In 
Frazier's" collection of thirty-five cases, twenty-five were markedly 
improved, no change occurred in six, and four died. 

Ill hereditary and familial spastic paralysis, in multiple or dissemi- 
nated sclerosis, and in myelitis, division of the posterior roots is only 
palliative. 

With regard to the selection of roots to be divided, Frazier^* cuts two 
out of every three possible sources of sensory stimulation, or, to put it 
in a different way, two of the three roots from which a given group 
of muscles derives its sensory supply. 

After division of the sensory roots there is always more or less pain 
until the proximal stump of the root has completely degenerated ; 
this lasts for four or five weeks. The spasticity will be varjangly 
under arrest from the beginning, the involuntary flexion of the limbs 
disappears, and voluntary movements, to a certain degree, gradually 
return. The preservation of the reflex defense indicates failure. The 
essential features of the after treatment are massage, faradization, 
passive movements, and mechanical and educational exercises. 

For the relief of gastric crises in tabes dorsalis, rhizotomy has been 
resorted to with varying success. Of 73 cases, the records show that 
14 were cured, 31 were improved, 5 were unimproved, and 16 died; 
of the last mentioned, 10 were operative deaths, and of the remain- 
ing 6, 3 were improved up to death. The methods of surgical attack 
upon the cord include intradural rhizotomy, extradural rhizotomy, 
extraction of the intercostal nerves, chordotomy, extradural gangliec- 
tomy, and ligature of both anterior and posterior spinal roots. Of 
these, the first seems to hold out the greatest hope of relief. A fair 
appraisal of intradural rhizotomy may be expressed in these terms: 



1468 



REGIONAL SURGERY OF THE SPINE 



two out of ten cases are cured, four are improved, three are unim- 
proved, and one dies (Frazier^*). 

Intradural anastomosis for the relief of paralysis holds out a fasci- 
nating possibility. There are as yet only two cases on record in which 
the results are reported, one by Kilvington and Bird,^" and one by 





Fig. 732. — Extradural Rhizotomy. 

The dura is grasped Avith mosquito forceps, with which the cord is rotated aud 
drawn to the opposite side. With a bluut hook the posterior root is separated 
from the anterior root. The extradural rhizotomy requires a wider exposure and 
the separation of the roots is more difficult because of the prolongation of the 
dural sheath (Frazier). 

Frazier.^^ The technic of the procedure includes the identification of 
the innervation of the paralyzed muscles and the proper selection of 
the substitute fibers — a problem of considerable difficulty. Frazier^* 
describes in great detail the technic employed by himself (see bibli- 
ography) . 



SURGERY OF THE SPINAL ROOTS 



1469 



Technic of Rhizotomy.— Rliizotomy implies cutting of the rhizome, 
or root, and, as a matter of fact, more than complete division is un- 
necessary; after the section is made, there can be no physiological 
niiioii with return of function. 

The rxfradtiral wrihod (P^igure 732) is supported on the ground 
that there is less risk, less danger of infection, and less danger of 




Fig. 733. — Intradural Ehizotomy. 

In the central figure the dentieiilate ligament is grasped with mosquito forceps, 
moderate traction on which rotates the cord and exposes the roots at their point 
of emergence from the cord and exit from the dural sac. With a small blunt 
hook the posterior root is separated from the anterior, a, A proximal and a dis- 
tal ligature of fine silk have been applied prior to division, b, The root is divided 
between the j^roximal and distal ligatures (Frazier). 



1470 REGIONAL SURGERY OF THE SPINE 

shock from the escape of cerebrospinal fluid (Guleki^*). It has the 
disadvantages of not being applicable to the lumbosacral region, -be- 
cause of the difficulty of separating the dura from the vertebrae and 
the necessity of making a wide exposure in order to attack the roots. 
The dangers of infection and those relative to leakage of fluid are 
easily taken care of. The intradural method affords an ample field 
for identification of the roots with a minimum of trauma to the tissues. 

Intradural rhizotomy is the method of choice at this writing. After 
the eord is exposed, as in laminectomy (p. 1472), the roots are identi- 
fied b}' their regional arrangement, not alwaj-s an easy matter. 
Frazier,^* as a substitute for cutting the root, uses "root ligation," 
solely as a means of securing hemostasis. He believes that the pres- 
ence of even small quantities of blood in the dural sac plays a part 
in the formation of adhesions, a belief which the writer shares. Fig- 
ure 733 conveys an excellent idea of the manipulations after the cord 
is exposed. The cord must be retracted a little to one side or the 
other, but this retraction must be gentle and never enough to trauma- 
tize the roots. As a prophylactic against the harmful effects of trauma, 
Frazier^* advocates the application of stovain to the cord and roots just 
above the area of manipulation. The method is supported by Waugh.^" 

The after effects in rhizotomy consist primarily in shock; surviving 
this, the patient complains of paiji, which is referred to the distribu- 
tion of the divided roots and which persists until degeneration is com- 
plete (three to five w^eeks). Anesthesia is more or less absolute or 
extensive according to the number of roots sectioned. Trophic dis- 
turhances do not occur, if every third or fourth root be left intact. 
In so-called Little's disease, Clark and Taylor-" have observed transi- 
tory trophic disturbances. In a few instances, the operation has been 
followed by temporary motor paralj'sis. 

BIBLIOGRAPHY 

1. Abbe. Boston Med. and Surs. Jr., 1896, cxxxv. 

2. Benxett. Med. Chir. Tr., 1889, Ixxii. 

3. FORSTER. Zeitst'hr. f. Orthop. Chir., Stutt,<rart, 1908, xxii. 

4. TiETZE. Mitt, a d. Grenzgeb. d. Med. u. Chir., Jena, 1909, xx. 

5. FoRSTER. Proe. Royal Soe. IMed., I^ndon, 1910-11, xliii. 

6. Chipault. Gaz. d. hop., 1897, lx\'iii. 

7. Jones. Jr. Amer. Med. Assoc. Cliicas^o, 1911. 

8. Mayo. Reported in Frazier No. 14. 

9. Horsley. Reported in Frazier No. 14. 

10. GiORDANi. Reported in Frazier No. 14. 

11. HiLDEBRAND. Arch. f. klin. Chir., 1911, xciv. 



SURGERY OF THE SPINAL ROOTS 1471 

12. Knapp. Boston Med. and Surg. Jr., 1908, clvii. 

13. KiLvixGTON. Brit. Jr. Surg., 1914, ii. 

14. Fkaziek. Surg, of tlie Si)ine and Si)inal Cord, N. Y. and London, 1918. 

15. Dejekine. Kev. neurol., l^uis, 1!)(JIJ, xi. 

16. KiLviNGTON. Brit. Med. Jr., London, 1907. 

17. Fbazier. Jr. Amer. Med. Assoc, Chieago, 1912, lix. 

18. GuLEKr. Centrbl. f. Cliir., Leipzig, 1910, xxxvii. 

19. Waugii. Brit. Jr. Surg., Bristol,'^ 1914. 

20. Clahk and Taylor. N. Y. Med. Jr., 1912, xcv. 



CHAPTER VII 

LAMINECTOMY — CHORDOTOMY 

The removal of the spinous processes and laminae, so-called "lami- 
nectomy," is performed for purposes of exploration, for the treatment 
of injuries to the spine and cord or of inflammatory lesions of the 
spinal canal and its contents, such as lues, actinomycosis and tubercu- 
losis, for the removal of tumors and cysts, and for operations upon the 
spinal roots. The tcchnic of the procedure is easy. The position of 
the patient is important. Figure 734 shows how the patient is pos- 
tured for exploration of the cervicothoracic region and it is not greatly 
modified when the lower segments of the spine are attacked. Endo- 
tracheal insufflatio7i ether narcosis is desirable; local anesthesia may 
be resorted to (Heidenhain^). The instruments employed for the 
purpose are those shown in connection with operations on bones and' 
joints (Fig. 332), in addition to- which, heavy bone cutting forceps 
should be available. The special equipment consists in a strong self 
retaining retractor (Fig. 735), Horsley's wax (p. 42), mosquito 
forceps, and small blunt hooks for picking up the spinal roots 
(Frazier^). 

The incision is similar to that employed in connection with osteo 
plasty of the spine (p. 1443) ; it should be ample and should allow of 
free exposure of the parts to be attacked. The separation of the 
muscles from either side of the spine and from the laminae is readily 
accomplished with the chisel used for splitting the spinous processes 
for bone grafting. After the hleeding is controlled by hot 
saline gauze tamponade, the self retaining retractor is introduced, 
the interspinous ligaments are divided, the spinous processes are re- 
moved with bone forceps (Fig. 735), and the corresponding laminae 
with rongeur forceps. 

The subsequent steps of the operation depend upon whether an ex- 
tradural or intradural problem is to be dealt with. Before the dura is 
opened the thin layer of fat, together with the plexus of veins, is dis- 
placed to either side. The dura is next lifted by means of fine silk 

1472 



LAMINECTOMY — CHORDOTOMY 1473 

sutures, opened with a. small slender knil'e, and held open with the silk 
traction sutures shown in figure 736. From now on the steps of the 
operation dejiend upon the nature of the lesion encountenMl. Tlie dura 
is closed with 00 silk introduced with a small curved iris needle, the 
muscle and fascia are approximated with catgut, and the skin closed 
with silk or silkworm gut. 




Fig. 734. — Position of the Patient on the Operating Table for Exploration 
IN Cervicothoracic Eegion. 

For adequate exposure of this region a suitable head rest is necessary, in order 
that the head and neck may be properly flexed. The apparatus attached to this 
table is capable of adjustment in any direction or angle (Frazier). 

The after treatment following laminectonn^ must take into consider- 
ation various conditions that do not pertain to operations elsewhere. 
The patient is at once placed upon a water bed. Fixation is neces- 
sary when the cervical region has been operated on; this is accom- 
plished with sand bags. In operations upon the lower sectors of the 
spme, the possibilit}' of contamination b.y the excreta must be taken 




Fig. 735. — Technic of Lamixectomt. Eemoval of the spinous processes (Frazier ) . 

1474 



LAMINECTOMY — CHORDOTOMY 



1475 



into account. It: there has been much leakage of cerebrospinal fluid, 
intense headache and vomiting- are very likely to occur. In these 




Fig. 73G. — Technic of Laminectomy. 

The appearance of the operative field after the dural flaps have been reflected 
with traction sutures (Frazier). 

cases the foot of the bed is raised. The liberal use of morphin is per- 
missible, as pain, in some instances, is very severe. The bladder and 
rectum must receive especial care. Frazier- employsi suprapubic drain- 



1476 



KEGIONAL SURGERY OF THE SPINE 



age of the bladder in cases in which this organ has been paralyzed for 
a long time. Frazier- furnishes a remarkably clear presentation of 
the teclmic of laminectomy. In addition to this, the works of Els- 
berg,^ Krause,* Schmeiden,"' and Thorburn*' may be consulted to ad- 
vantage. 

Decompressive Laminectomy. — As an operation for the relief of pres- 
sure upon the spinal cord, laminectomy is often followed by relief of 
symptoms. 

In tuherculaiis spondylitis it is effective in relieving the pressure 
sj'anptoms due to angidation, pressure upon the cord by a tuherculous 
exudate, and pres- 



sure from a dis- 
placed sequestrum. 
Of the cases ope- 
rated upon, Llo^'d' 
collected 154, 15 of 
which he did him- 
self. To be of ser- 
vice the operation 
must be performed 
before degenerative 
changes take place 
in the cord. 

In fractures and 
dislocations the re- 
moval of pressure 
has a beneficial 
effect, especially when due to the formation of reparative exudate. 

In inoperable tumors the measure relieves pain (see Spinal Tumors, 
p. 1464). 

For the relief of meningomyelitis, the first decompressive laminec- 
tomy was performed by Krause in 1911 ; four additional cases are 
reported by Taylor and Stephenson.^ 

Chordotomy. — Chordotomy is a term applied to an incision into the 
cord for the relief of various conditions. The procedure was suggested 
by Schiiller" as a substitute for division of the spinal roots in cases of 
gastric crises and spasticitj'; b.v Spiller^" in cases of unbearable pain 
in inoperable tumors of the cord ; and by Krause* and Taylor^ in cases 
of meningomyelitis. 

The operation (after two or more spinous processes and laminae are 




Fig. 737. — Diagrammatic Representation of Section 
OF AN Anterolateral. Column of the Cord, Show- 
ing THE Point at which the Cataract Knife is 
Introduced and the Direction in which the 
Incision Is Made. 

The shaded areas on the opposite side of the cord 
represent the anterolateral column, the direct cerebellar 
tract and the crossed pyramidal tract (Frazier). 



LAMINECTOMY — CIIORDOTOMY 1477 

removed) consists in exposure of the cord through a dural slit; tlien, 
with a cataract knife, the anterolateral columns of the cord are cut 
ill the iiiiiiiiu'r sliowu in tigure 737. The operation is of recent origin; 
its execution jjresupposes thorough knowledge of the anatomy and 
ph^'siology of the cord and a clearly demonstrated clinical justification 
for the procedure. For additional information see Allen,' ^ Cad- 
walader,^- Rothman," Exner,'^ and Beer.^'"' . 

BIBLIOGRAPHY 

1. Heidenhain. Zentrbl. f. Chir., Leipzig, 1912, xxxix. 

2. Fbazier. Sure', of the Spine and Si)inal Cord, N. Y. and London, 1918. 

3. Elsberg. The Surg. Treat, of Diseases of the Spinal Cord, N. Y., 1915. 

4. Krattse. Chir. d. Gehirn. and Riickenmarks, Berlin, 1911. 

5. Schmieden. Chir. Oper. Lehre., Ijeipzig, 1914. 

6. THORBURisr. Op. on the Spinal Cord, etc., System of Surg. London, 

1914. 

7. Lloyd. Jr. Amer. Med. Assoc., Chicago, 1901, xxxvi. 

8. Taylor and Stephenson. Jr. of Nervous and Mental Dis., N. Y., 1915, 

xlii. 

9. ScHiJLLER. Wien med Woeh., 1910, Ix. 

10. Spiller. Jr. Amer. Med. Assoc, Chicago, 1912, Iviii. 

11. Allen. Jr. Nervous and Mental Dis., 1914, xli. 

12. Cadwalader. Jr. Amer. Med. Assoc, Chicago, 1912, Iviii. 

13. ROTHMANN. Berlin klin. Woch., 1913, 1. 

14. ExNER. Mitt. a. d. Grenzgeb. d. Med. u. Chir., Jena, 1914, xxviii. 

15. Beer. Jr. Amer. Med. Assoc, Chicago, 1913, Ix. 



PART X 

SURGERY OF THE HEAD 



CHAPTER I 
SURGERY OF THE SCALP AND CRANIUM 

THE SCALP 

Wounds of the Scalp. — "Wounds of the scalp present a few regional 
peculiarities. Force, striking perpendicularly, produces simple 
wounds, striking ohliqiiehj, wounds with the formation of flap, or, if an 
entire portion of the scalp is torn off, wounds with loss of substance 
(partial or complete avulsion of the scalp). Simple wounds of the 
skin do not gape, those involving the aponeurosis do. Contusions of 
the scalp are likely to be attended with the formation of a hematoma. 
When these effusions are located beneath or in the skin, they are more 
or less circumscribed ; if beneath the aponeurosis, they may spread 
over the entire calvarium. 

Hematomata beneath the aponeurosis vary with their size ; the larger 
they are, the softer their consistence, the edges being hard, so that 
the impression of a depressed fracture of the skull is likely to be con- 
veyed to the palpating finger. 

The special treatment of wounds of the scalp relates to hematoma 
and loss of substance. As the former is usually absorbed it may ordi- 
narily be left undisturbed. However, if the effusion is very extensive, 
aspiration may be employed. Incision is resorted to onl}^ when pres- 
sure necrosis threatens or infection develops. In avulsion of the 
scalp, plastic methods of repair are often necessary. The great 
vascularity of the scalp and the presence of numerous hair follicles 
make the scalp pecularily resistant both to trauma and to infection, 
so that repair bj' suture of a flap left attached hy only a slender pedicle 
is often followed by healing. A useful method of repair in connection 
with a^^llsion of the scalp is shown in figure 738, 

Traumatic emphysema of the scalp occurs in connection with the 
establishment of a subcutaneous opening into the air sinuses of the 
cranial bones, most frequently after fracture of the frontal bone in- 
volving the frontal sinus, and at times the mastoid process. It usually 
disappears spontaneously^ (see Traumatic Emphysema). 

1481 



1482 



SURGERY OF THE HEAD 



Pneumatocele of the head is due to the same causes as traumatic 
emphysema, but the air is located beneath the periosteum. The col- 
lection of air raises the periosteum into a tense, more or less circum- 
scribed, elastic timior which may be reduced when the contents are 
forced into the sinus it communicates with by palpation, and increase 
in size during forced expiration. The communication with the frontal 
or mastoid sinus may be congenital or may be established by caries or 
be the result of trauma. 

The treatment of 'pneumatocele cranii consists in exposure of the 
opening and removal of carious bone — when present — and closure 
of the defect in the bone by osteoplastic methods (p. 1566). 





Fig. 738. — Plastic Eepair of Scalp. 



Tumors of the Scalp. — Lipomata (see p. 1134) of the hairy scalp are 
rare ; they are likely to be very vascular. The growth is differentiated 
from dermoid cysts by the invariable location of the latter. The 
treatment consists in excision, usually not a difficult matter, although 
control of bleeding may be troublesome. . 

Fibromata (p. 1119) of the scalp usually appear in papillomatous 
form. Four types may be .distinguished, (1) soft multiple fibromata 
— fibromata mollusca — which originate in the sheaths of the cutaneous 
nerves; (2) the pigmented "neuronevi," in which regular, minute 
fibromata are attached to the terminal twigs of the eutaneous nerves; 
(3) the "racemose neuromata," in which coils of the thickened nerve 
fibers — cjdindrical or spindle shaped — are twisted and intertwined 



SURGERY OF THE SCALP AND CRANIUM 1483 

like grapeviuesj ; and (4) elepliaiitiasis of neuropathic origin, or ele- 
phantiasis neuromatosa congenita. The four may exist in combina- 
tion with one another. 

Treatment by excision is complicated with the danger of bleeding, 
which is likely to be menacing. It may be necessary to remove the 
growtli in sections. When tlie process is extensive, plastic repair of 
the denuded area is necessary. 

Angioma frequently develops in the scalp. It occurs in three forms, 
angioma simplex, angioma cavernosum, and angioma arteriole race- 
mosiim (see p. 1158). 

Angioma simplex (telangiectasis or nevus vasculosus) appears most 
often upon the face and is usually situated on the forehead in the 
region of the glabella and the inner portion of the eyebrows, though 
it also appears at the fontanelles, sutures, parietal eminences and 
frontal tuberosities. Telangiectasis may occur alone or in combina- 
tion with other forms of angioma and with lymphangioma. 

The treatment with caustics or by excision is described above 
(p. 1163). 

Cavernous angioma, as already stated (p. 1161), is composed of a 
spongy mass of blood filled sinuses. They not infrequently communi- 
cate with the longitudinal and transverse sinus. 

Excision is a desirable method of treatment. However, when it is 
evident that the tumor communicates with one of the large cranial 
sinuses, it is best to employ multiple puncture with the thermocautery. 

Racemose arterial angioma (cirsoid aneurism), described on page 
1164 (Fig. 566), frequently occurs on the scalp, and usually develops 
in the course of a large vessel communicating with the carotid artery. 
The diagnosis is not difficult and is discussed on page 1166. This form 
of angioma must be differentiated from pulsating sarcoma, from ar- 
terial aneurism, and from arteriovenous aneurism. 

The treatment is discussed on page 1166. Of the various methods that 
of ligature of the afferent arteries and total extirpation is the least 
unsatisfactory. In fact, if this is done early in th« process, the result 
is likely to be gratifying. 

Aneurisms (p. 976) of the scalp are infrequent. Simple aneurism 
of arteries supplying the scalp is almost always caused by some 
injury of the vessel. The superficial temporal, because of its extensive 
distribution and its superficial course, is the one most exposed to vio- 
lence and is most often the seat of aneurism. The aneurism may be 
sacculated or spindle shaped. The diagnosis presents no difficulties. 



1484 SURGERY OF THE HEAD 

The treatment of aneurism in this siituation consists in extirpation 
of the sac. 

Arteriovenous aneurism (p, 981) also occurs most frequently in the 
region of the superficial temporal artery and is the result of injury to 
this vessel, usually in connection with a punctured wound. The most 
conspicuous 9y>niptom is dilatation of the superficial veins. 

The diagnosis is taken up on page 986. 

The treatment consists in double ligature and excision of both artery 
and vein (for extended discussion see p. 990). 

Sinus pericranii is a peculiar cyst-like growth filled with blood, situ- 
ated beneath the cranial periosteum and is connected with the longi- 
tudinal sinus by a wide emissary vessel. It has some of the charac- 
teristics of subcutaneous cavernous angioma. The lesion is prohably 
traumatic in origin and is situated in the middle of the skull, on the 
forehead, or on the occiput. It is covered with normal or slightly 
atrophic skin and is rarely larger than a walnut. It is soft and elastic, 
and may be forced into the hollow of the skull, where a cleft may be 
felt in the bone or a bony ring about the base of the tumor. The growth 
increases in size and becomes tense when the head is lowered, or when 
the patient coughs or sneezes. 

The treatment by continuous pressure is not usually successful. In 
one case Krause^ exposed the growth by lifting the skin from it in 
the form of a flap, and drilling the bone contiguous to the emissaiy. 
Through this opening he tied the emissary, excised the now bloodless 
tumor and closed both openings in the skull by means of an osteoplastic 
flap fashioned from the contiguous skull. The method is described in 
detail and the steps of the operation are shown in a series of illustra- 
tions (see bibliography No. 1). 

Sarcoma (p. 1172) of the scalp occurs either as sarcoma of the skin 
or of the fascia. The first originates in the intact connective tissue of 
the skin or subcutaneous tissue, or develops secondarily to some dis- 
turbance in the normal structure of the tissue, as from keloid, warts 
or pigmented moles. Its clinical course does not differ from that of 
sarcoma in other parts of the body. There are two types, soft nodu- 
lar tumors, and icarty grotcths. The former may be elevated above 
the level of the skin and have overhanging mushroom-like elges. 

The melanotic sarcomata (p. 1200), developing secondarily in small 
pigmented moles or warts, have a particularly malignant character. 
They occur as diffuse nodular growths or in the form of numerous hard 
knots and have a tendencv to form earlv metastases. 



SURGERY OF THE SCALP AND CRANIUM 1485 

In sarcomatous warts, oii the other hand, the outlook is less unfavor- 
able. When these are excised they show little tendency to recur. 

Because of the ^reat vascularity of the scalp, sarcomata are very 
likely to be of the pulsating variety. 

Sebaceous cysts (atheromata) are the most frequent form of tumors 
of the scalp. Their structure is not different from that of cysts of the 
same character located elsewhere on the body. Thc}^ are very likely to 
be multiple, and at times reach, great size. Small cysts are hard, large 
ones are always soft. The latter usually fluctuate. The superimposed 
skin is thin and pale. Very often the summit of the tumor shows pitted 
hair follicles destitute of hair, or it may be the seat of a comedo. Their 
structure and contents are described on page 1316. Occasionally a 
sebaceous cyst of the' scalp becomes malignant. 

The treatment consists in excision in toto. If a portion of the sac is 
left, the growth returns. 

Dermoid cysts (p. 1237) occur on the head, as they do elsewhere on 
the body, before the second or third year of life. The skin over them 
is unaltered. They are found beneath the skin and below the aponeu- 
rosis of the occipitofrontalis muscle. In some instances such a cyst is 
so intimately associated with the periosteum that a sector of this mem- 
brane must be removed with it. 

Dermoid cysts are distinguished from other cystic and solid tumors 
by their deep situation and their constant location. They are found in 
the neighborhood of the anterior fontanel at the outer edge of the 
supra-arhital margin and the contiguous temporal region; also at the 
inner angle of the eye, over the glabella and the root of the nose. 
These situations correspond to the points of union of the embryonic 
clefts. 

The treatment consists in extirpation of the growth. This is es- 
pecially important in children, in whom the tumor interferes with the 
normal development of the contiguous bones. 

Carcinoma (p. 1253) of the scalp originates from the skin. It does 
not present any regional peculiarities, except perhaps that its growth 
is likely to be very slow. Its development in connection with sebaceous 
cj^sts should be borne in mind. In the treatment, the accessibility 
of the growth and its slow progress may tempt the surgeon to employ 
caustics and ''light therapy." Early and complete removal is the 
correct treatment and when thoroughly executed, there is little likeli- 
hood of a return of the growth. 

Inflammations of the Scalp. — Erysipelas (p. 264) occurs in the scalp 



1486 SURGERY OF THE HEAD 

more often than in anj'^ other portion of the hody. It often arises in 
connection with suppurative otitis media and during its onset is fre- 
quently mistaken for mastoiditis. 

The temperaiure in erysipelas of the scalp is very JiigJi and is at- 
tended with delirium, semistupor, and muscular twitching formerly 
regarded as indicating meningitis, Memngitis in connection with ery- 
sipel'as of the scalp occurs when streptococcus infection extends to the 
cranial cavity through the site of a fracture or by means of an osteo- 
myelitis traversing the bone, and also by extension of thrombosis of the 
veins of the scalp through the emissaries to the longitudinal sinus. 

Abscesses of the scalp are a frequent sequel of erysipelas. Among 
the most serious are those in the adipose tissue of the orbital cavity, 
whence they may extend to the brain. In many instances temporary 
alopecia occurs. 

As a rule, the prognosis is good ; it depends largely upon the com- 
plications. 

The treatment is purely symptomatic. 

Phlegmons of the scalp are either circumscrihed or diffuse. The 
circumscribed form appears as a furuncle or carbuncle (staphylo- 
coccus). The diffuse phlegmons (cellulitis purulenta), on the other 
hand, are usually caused by the streptococcus family and are likely 
to involve extensive areas of the scalp. As they are situated both 
above and below the aponeurosis, they frequently cause necrosis of the 
latter. In not a few instance, the external table of the skxdl is de- 
stroyed. The process involves great danger of extension to the brain, 
especially in infected punctured wounds. 

The treatment consists in early, free, deep incisions through the 
aponeurosis and periosteum to the bone. The incisions should be 
planned to provide for free drainage at the supra-orbital ridge, the 
mastoid and the occiput. Light tamponade with iodoform gauze is 
permissible for a few days only. 

THE CRANIUM 

Fractures of the Skull. — Fractures of the skull, as such, have no 
particular significance ; their importance pertains to their relationship 
to the brain. The outcome of injuries of this class depends very little 
upon their form and extent at the time, but relates to the trauma in- 
flicted upon the brain and its vessels. There are portions of the brain 
which bear trauma without much disturbance of function, while at 



SUllGEKY OF THE SCALP AND CRANIUM 1487 

the buiao comparatively slight inju-iy becomes a serious matter. Frac- 
tures of the skull may be divided into those of the vault and those of 
the base. 

The varioKs forms of fracture of the skull do not differ from those 
described in the chapter on fractures (p. 639). However, the confor- 
mation of a fracture in this situation possesses peculiar clinical im- 
portance. 

Fissured Fractures. — Fissured fractures appear in the form of 
cracks or splits. They occur as the result of a bursting or bending 
force (see mechanism of fracture of the skull, p. 1489). As a rule, the 
edges do not gape. They may be single or multiple, simj^le or forked, 





a h 

Fig. 739. — a, Central Depression; &, Peripheral Depression. 

or divided hito many branches, and may be limited to one bone or may 
involve several. They may be short or long, straight or curved. They 
often cross the lines of the sutures, though they are likely to change 
direction when this occurs. Finally, fissured fractures often occur 
in connection with penetrating gunshot fractures, with splintered and 
comminuted fractures, and with those attended with loss of substance. 
Comminuted Fractures. — Fragmented, comminuted and splint- 
ered fractures are common. In the fragmented fracture there is only 
one line of fracture. It encircles an area of the skull in a curve or in 
an angular line separating its connection with the rest of the skull. 
It is the outcome of a bending force. In splintered or comminuted 



1488 



SURGERY OF THE HEAD 



fractures a greater or less proportion of the skull has been broken 
into a number of pieces. The splinters may or may not be separated 
from the soft parts. At times the arrangement of the fragments justi- 
fies the use of the term stellate fracture. 

The degree of displacement in fracture of the skull has an import- 
ant bearing on the outcome, especially when the fragments encroach 
upon the cranial cavity. Accordingly^, fractures are divided into 
those WITH, AND THOSE WITHOUT DEPRESSION. The entire fragment 
circumscribed by the line of fracture may -be depressed {peripheral 
depression) (Fig. 739). In this case the external table of the de- 
pressed center is usually fissured, while the internal table, still more 
depressed, is always more extensively separated. Figure 7-lOA shows 



^o'-CJZl 





Fig. 740.- 



A, Fracture of the Outer T^uble op the Skull; B, The Same 
Fracture from Within. 



the outer and B shows the inner aspect of a fracture of this part. At 
times the depressed disk of bone is either broken into manj- fragments 
or Ls only slightly cracked ; at others, the fragments are pushed over 
one another, or under the adjacent edge of a fracture between bone or 
dura, or are displaced laterally. They may penetrate the dura and 
become embedded in the brain. It is these possibilities that make 
splintered fractures a source of great danger to the patient. 

Perforated Fractures — Perforated fractures and fractures with 
loss of substance are the result of gunshot wounds of the skull or are 
caused by penetrating hooks, or falling spikes, or both. The mechan- 
ism of gunshot wounds is discussed farther on. Extensive loss of 
substance is caused by shell fragments. In comminuted fractures 



SURGERY OF THE SCALP AND CRANIUM 1489 

in which the skull is broken into many pieces, some of the frag- 
ments are entirely separated, tearing- extensive openings in the vault 
of the cianium. The various forms of fracture involve either both 
tables to the same extent, the inner table more than the outer (as is 
usually the case), or only one table. Under the latter circumstances, 
the inner or outer table may be involved alone. The outer table may 
show little, if any, injury, yet the inner (lamina vitrea) may be 
splintered — the so-called isolated fracture of the inner table. Frac- 
ture of the outer table alone occurs, but is rare. This is important, 
as even a slight fissured fracture of the outer table is almost 

CERTAIN TO MEAN SOME SPLINTERING OF THE INNER. 

In the mechanical processes in'dolved in fracture of the skull it must 
be remembered that two things determine the elasticity and rigidity of 
the skull, the character of the material (the bony tissues entering into 
its construction) and its shape. The elasticity of the bony tissues is 
that quality by which these tissues resume their original form when 
distorted by stress or strain. This qualitj^ has been placed on a mathe^ 
matical basis by Rauber.- The distortion produced by violence caused 
hy a broad smooth surface is not limited to a circumscribed portion, 
but produces a change in form of the entire skull. If, in a fall, the 
skull strikes a- broad surface, or is struck by a blow from a broad 
surface, the vertical diameter is shortened, while at the same time 
the occipitofrontal and biparietal diameters are increased. The 
particles in the direction of the increased diameters are drawn apart, 
and those in the diminished diameters are pressed together, until at last 
the skull breaks or, more properly speaking, bursts. 

As the skull is elastic, the lines of fracture must gape when the 
skull is burst or fractured, but as soon as the violence ceases to act 
they return to their original position and become closed. This ex- 
plains how orbital fat is caught in fissures in the roof of the orbit; 
also, dura mater and hairs. Considering the elasticity of the skull, 
we may divide fractures into two forms, bending fractures and burst- 
ing fractures. These include all fractures of the vault and base, even 
the fissured, comminuted and perforated. The mechanism of bending 
fractures is more clearly defined in those produced by. objects and 
instruments of relatively small surface; that of bursting fractures, in 
those produced by violence caused by extensive surfaces. Whenever 
the skull is compressed in any given diameter, there is a shortening 
in the direction of pressure, while the diameters of the circles perpen- 
dicular to this line of compression are increased. The form of the 



1490 SURGERY OF THE HEAD 

SKULL IS CHANGED IN THESE DIRECTIONS BY EVERY VIOLENCE, WHETHER 
ACTING ON A LIMITED OR CIRCUMSCRIBED AREA OR MORE EXTENSIVELY. 

According to the extent of the surface possessed by a striking body, 
an area of skull is flattened, then depressed and bent in. If the 
action be momentary, as in a blow, and its force exhausted by the 
elasticity of the depressed portion of the skull before its limit of 
elasticity has been reached, the cranium rebounds to its former posi- 
tion and no permanent change results. The bending, however, results 
in fracture when the molecules of the skull have reached a degree of 
separation in which the force of cohesion no longer suffices. This 
takes place first in the inner table, the solitary fracture of which is 
thus explained. The mechanism of this fracture may be illustrated by 
observing the w^ay a stick breaks when bent over the knee, i. e., the 
fracture begins on the side opposite the causative force. 

At the site of a dent in the skull there are always found cracks and 
fissures and, in the majority of cases, comminution and splintering 
(except in the skulls of infants). 

While ^'bending fractures" are the result of violence immediately 
at the site of impact, bursting fractures occur in response to a 
CHANGE IN THE FORM OF THE ENTIRE SKULL. By the Combination of 
bending and bursting fractures, those lines of fractures are explained 
that surround extensive comminuted fractures and radiate in many 
directions. The irregularity in thickness of the various sectors of the 
skull renders the establishment of a definite mathematical rule in this 
connection impossible. 

Bursting fractures in comhination with bending fractures are best 
studied at the base. The greatest degree of tension sustained by the 
flattened meridian circles is at their midpoint where they cross the 
equator of the sphere. At this place bursting should begin in each 
instance. As, however, the base of the skull possesses greater rigidity 
than its convexity, the bursting almost always occurs in the basal por- 
tion of the meridian. Compression from side to side produces the 
greatest degree of deformity and readily causes the skull to burst. 
This is observed when a wagon wheel passes over thr- head, the frac- 
ture being usually a bursting, transverse one through the base, com- 
plicated hy a h ending fracture of the vault on the side receiving the 
impact. In a certain sense, compression of both sides of the skull also 
takes place in falls in which the head is struck. In this case the skull 
strikes the ground, but the spinal column following after, is driven 
against the condyloid processes of the occipital bone with the weight of 



SURGERY OF THE SCALP AND CRANIUM 



149], 



the body and the velocity- of the fall. The atlas striking a^^ainst a cir- 
cumscribed area of skull brings about the lateral circles of a bent-in 
fracture {ring fracture). 

Isolated short fractures of the hase are incomplete bursting frac- 
tures. They occur in the orbital plates, usually on both sides at the 
same time. 

Besides bending and bursting, expansion must be mentioned as a 
factor in the production. of fracture of the skull. This is taken up; 
more extensively in connection with gunshot fractures (p. 914). 
The diagnosis of fracture of the skidl before the advent of the Ront- 

genogram was a much more dif- 
ficult matter than it is at this 
writing. With the technical re- 
finements of modern Rontgen- 
ology, few fractures of the skull, 
including those of the base, 
escape recognition. 

Though important as regards 
prognosis, cerebral manifesta- 
tions usually accompan3'ing 
fractures are of little aid in mak- 
ing the diagnosis of fracture. In 
simjjle fractures palpation of the 
surface of the skull is of aid in 
discovering a fissure, the edge of 
a fracture, or an area of depres- 
sion., but this is only possible 
when the last is of considerable 
depth. Extensive comminution 
of bone is more easily determined 
in this way. In this connection must be excluded (1) depressions pro- 
duced in the course of parturition and by previous injuries; (2) senile 
atrophy of the skull;' (3) the hollows due to lues; (4) the natural 
prominences and irregularities, the result of peculiar cranial confonma- 
tion. Difficulties in examination arise in connection with contusions 
of the soft parts. Here flat hematomata wi4;h a hard firm base often 
lead to error. The diagnosis of subcutaneous fractures (except by 
X-ray) can be made with certaintj^ only in those cases in which there 
is displacement toward the cranial cavity, or in which fragments have 
broken loose. Fortunately the welfare of the patient is rarely depend- 




FiG. 741. — Circular Bending Fracture 
OF THE Skull, with Linear Bursting 
Fracture Extending into the Left 
Anterior Fossa, 



1492 SURGERY OF THE HEAD 

ent upon the positive diagnosis of subcutaneous fracture. At the 
present time, the exposure of an area of the skull by incision for the 
purpose of diagnosticating fracture is not practiced. In cases of sub- 
cutaneous fractures of the skull, operative interference is necessary 
only for relief of accompanying lesions of the cranial contents, not 
because of the fracture itself. 

When there is a wound of the soft parts and its communication with 
a fracture is suspected (compound fracture), this may be determined 




Pig. 742. — Bending and Bursting Fracture. 

Bending fracture outlined bj dotted line; bursting fracture by continuous line. 
Fracture caused by bilateral compression; point of impact the occipital region. 
Poles connected by bursting fracture (4), wliieli begins on the vault at the bend- 
ing fracture and passes through the posterior fossa, then through the clivus, sella 
turcica, and roof of the orbit. The bursting fracture (2) passes over the left 
parietal to the external angular process of frontal; the fissure (3) has a short 
course, while (5) passes over the right parietal to the great wing of the sphenoid 
and ends in the sphenotemporal suture. 

by the sense of touch and sight. For the purpose, the exploration is 
made under aseptic precautions, with the patient narcotized. If these 
conditions are not possible, it is best not to meddle with the injury, but 
to cleanse and treat it as described in connection with wounds in gen- 
eral (p. 3). 

The question of injury to the dura is of great prognostic importance. 
This is determined during the examination as stated above ; the extru- 
sion of brain substance of course makes this certain. 



SUIKJEKY OF THE iSCALP AND CRANIUM 1493 

The syniptonis of fractures of the base are indirect. The points in 
their diagnosis are as follows : 

1. The spreading of hemorrhages from the site of fracture to cer- 
tain points under the skin, whore they appear as eechymoses. 

2. The flow of brain tissue, blood, and serous fluid from those 
cavities contiguous to the base. 

3. The disturbances in function of the cranial nerves emerging at 
the inferior surface. 

Extravasations of blood appear where the skin and mucous mem- 
branes are attached to the base of the skull by loose connective tissue. 
These sites correspond to the eyelids and the connective tissue of the 
eye, the mucosa of the pharynx, the region of the mastoid process, and 
the sides of the neck. Their appearance, however, is positive evidence 
of fracture only when the site of the injury is at some distance from 
them and the extravasation does not immediately follow the trauma. 
The so-called "black eye" is especially misleading, and is of diagnostic 
value only under the conditions stated. Exophthalmos occurring im- 
mediately or soon after violence, followed by ecchymosis of the con- 
junctiva and eyelids, is an indubitable sign of orbital hemorrhage and 
of fracture of the base. Ecchymosis into the mucosa of the pharynx 
is rarely observed. The dense connective tissue in this situation does 
not favor its extension. Ecchymosis in the region of the mastoid 
process indicates a fracture in the squamous portion of the temporal 
bone. 

The flow of brain tissue, from clefts of bone produced by fracture, 
through the divided soft parts is a positive sign of fracture of the base 
and, at the same time, of injury to the membranes of the 43rain. This 
has been observed at the external auditory canal and the nose; the 
latter is uncommon. 

The hemorrhages from cavities and canals that adjoin the base take 
place from the car, the nose, and the pharynx. The flow of blood from 
the ear possesses the greater diagnostic value. It escapes through the 
bony canals and fissures in the petrous portion of the temporal bone. 

Hemorrhage from the ear may originate from (1) bursting and 
laceration of the ear drum; (2) fracture of the anterior wall of the 
external auditory meatus; (3) violent separation of the cartilaginous 
and bony portions of the auditory canal ; (4) a fracture involving the 
mastoid cells; (5) fissures and fractures of the base of the skull. 
Again, not every fracture of the petrous portion is attended wuth 
hemorrhage from the ear ; it occurs only when the drum is ruptured. 



1494 SURGERY OF THE HEAD 

In these cases the blood gains access to the pharj-nx hy way of the 
eustachian tube and is swallowed or rejected or flows out through the 
nose. In the, last instance, the blood maj^ come from a fracture of 
the horizontal plate of the ethmoid. 

The flow of serous fluid from the ears in fracture of the hose is a 
sjTnptom of fracture of the petrous bone. The fluid comes from the 
subarachnoid spaces, proving that the tympanum is ruptured. The 
flow of fluid may take place immediately after the injury-. In most 
cases, however, it does not appear until twenty-four hours later. The 
quantity of blood is always large, 150 to 200 gms. ; even more is not 
uncommon. When, in cases of fracture of the petrous bone, the 
tympanum remains intact, the fluid may flow through the eustachian 
tube into the nares. It may flow from the ear and the nose at the 
same time. 

Paralyses of single cranial nerves are produced by fractures that 
traverse the canal or foramen through which the nerve emerges from 
the skull. The nerve is either lacerated, divided, compressed, or can- 
tused. The result of the injury is immediate paralysis of the part 
supplied by it. Besides this, a second form of paralysis develops as 
a result of an inflammation extending along the nerve trunk ; this is 
usually ascending. The facial nerve is most frequently paralyzed. 
A number of cranial nerves may be paralyzed at the same time (v. 
Bruns^). 

According to Stewart,* Rontgenographic examinations show that 
"in over fifty per cent of the cases, both the vault and the base are 
found fractured. In three hundred cases of head injure-, twenty' per 
cent showed fracture of the .skull. While objective signs, such as 
bleeding from the ears, etc., may give a clue to the location of the 
fracture, these may be misleading and in every case a .systematic 
radiographic technic must be followed." Stewart's* presentation 
goes into great detail in this connection, .suggesting a method of pro- 
cedure in which the entire vault and base of the skull is visible on the 
negatives. The proper interpretation of the radiogram presupposes 
a knowledge of the normal sutures and fissures and foramina of the 
skull. Stewart emphasizes the value of the stereorontgenogram. 
This is especially true in linear fractures extending into the roof of 
the orbit. 

In the course of fractures of the skull, the bony lesion is not of great 
importance : the sigxeficaxce of the estjury lies ix the compijcat- 

EN'G IXVOL\'EMEXT OF THE CONTENTS OF THE CRANIUM and in INFECTION. 



SURGERY OF THE SCALP AND CRANIUM 



1495 



The dang^crs of concussion, compression, contusion and laceration of 
the brain are common to all fractures of the skull ; the dangers of 
infection of the connective tissue, the bone, the meninges, and the 
development of brain abscess and sinus thrombosis are factors onh' 
when injuries of the soft parts communicate with the seat of fracture. 
The involvement of the cranial contents determines the therapeutic 
prohhm (v. Bergmann'). This is taken up farther on. The un- 
favorable factor in fractures of the base relates not to the bone 




Fig. 743. — Eoxtgexogram of Fracture of the Vault of the Skull (Harlem 

Hospital case). 



lesion, but to the brain injury. The fracture, of itself, is not suscep- 
tible to surgical measures of relief. 

The so-called provisional callus of fractures in general is not found 
in fractures of the skull ; this is ascribed to the absence of irritation 
from muscular movements which determine its development in the 
former, and to the destructive force of the trauma in the latter. 
Fractures of the skull are directly repaired hy osseous closure of the 
fissures and clefts. This takes place even in the most extensive frac- 



1496 SURGERY OF THE HEAD 

tures and includes loose fragments. Fractures with loss of substance 
are followed hy residual defects. 

The treatment of fractures of the skull in cases of .subcutaneous 
lesions is different from that of those complicated by wounds of the 
soft parts. 

Subcutaneous fractures, unless attended with symptoms of involve- 
ment of the cranial contents, or with marked depression shown in the 
Rontgenogram, are hest treated expectantly. 

In COMPOUND FRACTURES OF THE SKULL THE TREATMENT, kS FAR AS 
THE BONE LESION IS CONCERNED, IS PRECISELY THAT OF A SIMILAR INJURY 

INVOLVING THE TIBIA. Detached splmters may be removed or placed 
into the niveau of the skull ; moderate depression may be disregarded. 
The question of trephining for depressed fracture per se may bei 
answered as follows : Slight depression cannot possibly be responsible 
for cerebral compression ; the latter may be due to intracranial bleed- 
ing coincident with a fracture, but this occurs when there is no bony 
depression. It often happens that a splinter of bone penetrates the 
brain and is responsible for focal symptoms, but this is not in any 
sense a cerebral compression caused by a depressed fracture, and indi- 
cation for operation is presented by the focal sj^mptoms (restricted 
spasm and parah'sis). The notion that epilcpsij is caused by the pres- 
sure of a restricted area of hony depression and that this contributes 
an indication for operation is also not tenable. Epilepsy follows head 
injuries without fracture and is due to a lesion of the brain or its 
coverings and subsequent scar formation. This is explainable on the 
basis that in these injuries the trauma has not exhausted the, elasticity 
of the bone, that the latter reassumes its normal outline and the con- 
tused brain area underneath becomes sclerosed and is responsible for 
so-called jacksonian epilepsy. The removal of the depressed area of 
bone does not prevent the subsequent development of the latter 
(Kiittner^). 

In the treatment of compound fractures, the wound is cleansed, 
splinters of bone are removed and large fragments are placed in their 
normal relationship. This is accomplished by free exposure of the 
injury and is followed by the usual treatment of wounds. The pri- 
mary cleansing of the wound and its repair are aimed at prevention 
of infection, and are not destined to provide an unusual method of the 
treatment of fractures. It may well be added that the development 
of infection in this situation is attended with such grave menace that 
no precaution in this connection may be omitted. In cases of exten- 



SUKiJEKY OF THE SCALP AND CRANIUM 1497 

sive loss of substance, the question of immediate osteoplastic closure 
of the defect must be given serious consideration. This is of course 
permissible only when there is reason to believe that infection has not 
occurred. However, in most cases, the closure must be postponed 
until danger in this connection no longer exists. The special dangers 
of infection pertain to leptomeningiiis purulenta and to suppurative 
infection of the hone. The latter is treated in the same way as is 
osteomyelitis elsewhere in the body. 

The treatment of fracture of the hase of the skull aims at the pre- 
vention of infection. This consists more in withstanding the tempta- 
tion to meddle than in active measures of relief. As the infection 
enters through the cavities of the face and ears, these must be kept 
clean. The latter may be lightly tamponed with iodoform gauze, the 
tampon "being changed as soon as soiled. Tamponade of the nasal 
passages is inadvisable. In cases in which the effusion of blood is 
attended with the clinical picture of cerebral compression, the question 
of affording an avenue of egress for the fluid must be taken into 
account. For the purpose, Gushing'^ approaches the middle fossa of 
the skull by exposing the temporal bone immediately above the zygoma, 
opens the squamous plate with a burr, and enlarges the opening with 
a rongeur forceps. The procedure has a certain limited field of use- 
fulness. When purulent meningitis has developed, the employment 
of the decompressive craniotomy must also be given consideration. 

Incised, Punctured and Gunshot Wounds of the Skull. — The surgical 
importance of incised wounds of the skull may be divided into (1) 
simple cuts limited to the outer table; (2) division of both tables; 
separation of a flap; (4) complete separation of a segment of the 
skull in which the bone may remain attached to the soft parts, or both 
may be cut off at the same time. Wounds of this sort may be classified 
as penetrating, or nonpenerating . 

These injuries usually run a favorable course. The outcome is 
dependent npon the concomitant hrain injury and upon the develop- 
ment of infection. 

The treatment in all essential regards is similar to that of compound 
fracture. 

Punctured wounds of the skull are very likely to involve the cranial 
contents and frequently arc infected. The roof of the orbit is espe- 
cially liable to injuries of this sort (pointed tools, bayonets, arrows, 
etc. ) . In not a few instances a portion of the invading instrument is 
(3) oblique or horizontal splitting of both tables without complete 



1498 SURGERY OF THE HEAD 

left wedged into- the cleft iu the bone. Other than the danger of 
infection, the possibility of the retention of a foreign body makes this 
kind of injury a serious one. Verification by radiogram is of great 
help in the diagnosis. The treatment is also similar to that of com- 
pound fracture. In addition to this the foreign body must be removed 
(see Technic of Trephining, p. 1564). 

Gunshot ivounds of the skull have been surrounded with an atmos- 
phere of mystery which would not seem justified. As a matter of fact, 
as far as the surgical problem is concerned, the clinical factors in this 
class of injury differ from those encompassed by the study of compound 
fractures in this situation only with regard to projectiles fired at close 
range, and this relates to the fact that, in addition to the bursting and 
bending effect of the projectile, the hydrodynamic action of the fluid 
canstituents of the hrain is operative with regard to the extent of the 
lesion. This w^as worked out by v. Color and Schjerning^ in 1894, 
and remains unchanged at this writing. Thus, the action of projec- 
tiles fired at close range becomes expansive in character and is attended 
with severe injury of the entire brain in the form of diffuse hemor- 
rhages and areas of contusion, the ventricles being filled with fluid 
blood, which is present even when projectiles traverse only the bone. 
It would seem permissible ta classify gunshot wounds of the skull 
(other than those fired at close range) Mnth the bending and bursting 
compound fractures due to other causes, the extent of the lesion 
depending upon the velocity of the projectile at the moment of im- 
pact. That a projectile may strike the skull directly or at an angle 
goes without sa3'ing, and that the resultant lesion would not differ in 
character from that produced by other agents, such as an ax, a ham- 
mer, or a pick, is equally patent. Indeed, it not infrequently happens 
that the impact of a projectile is so slight that it (just as any other 
force) does not exhaust the elasticity of the bone at the point of con- 
tact, and that the latter reassumes its normal shape without fracture, 
as already described in connection with simple fractures (p. 1489). 

Gunshot wounds, like punctured wounds, may also be divided into 
penetrating and 7ian^penetrating. To this may be added the fanciful 
class of penetrating gutter wounds of the skull in which the bullet 
plows a furrow in the bone ; yet these injuries may be very properly 
classed with wounds of the skull with restricted loss of substance. 

The treatment of recent gunshot ivounds of the skull does not differ 
from that of similar wounds of the extremities and joints. Apart from 
rapidly increasing cerebral pressure, the element to be most feared in 



SURGERY OF THE SCALP AND CRANIUM 1499 

gunshot wounds is infection, and this pertains especially to the cranial 
contents. Aside from the first aid dressing, discussed elsewhere (p. 
57), the question as to whether wounds of this sort sliould be ch)sed 
at once, or treated as infected wounds and left open, has occupied the 
attention of surg-eons for many j^ears, and with widely divergent con- 
clusions. Especially in the recent war has there been a tendency to 
practice the former method, though this is not by any means universal. 
If the factors adduced in this connection (p. 1480) are based on the 
proper conception of the ''mechanism of infection," then gunshot 
wounds should never be closed, but should be treated by the open 
method. In perhaps the most recent work pertaining to this class of 
cases, Chatelin and De MarteP say "The surgeon must be satisfied 
with facilitating, with judicious drainage, the elimination of all dead 
material, the presence of which provokes and encourages infection. 
Men wounded in this way never die of osteomyelitis; that is not the 
danger. The immediate danger is, almost exclusively, meningitis, and 
the natural defenses of the wounded man are much more effective 
against it than is the illusionary help of surgery." 

Diseases of the Skull. — Rachitis of the skull (craniotabes) is a part 
of a general rachitic condition characterized hy persistence of the 
fontanels and the soft consistency of the bones, especially of the occip- 
ital, which cause it to become flattened (tete carree) . It may be mis- 
taken for congenital hydrocephalus. For the treatment see page 1503. 

Osteomalacia, chronic osteitis deformans, and osteoporosis of the 
skull are uncommon. 

Tumors of the Cranial Bones. — Osteomata of the skull are usually 
situated on the frontal and parietal bones. They may be located on 
the external or internal surfaces of the skull or on both, and are often 
multiple. Traumatic origin has been claimed, but not proved. 
Exostoses of the orhit are of especial interest. They are usually 
located in the labyrinth of the ethmoid bone. Their development has 
been studied by Bornhaupt.^" The diagnosis rests on their slow growth 
and the Rontgenogram. They must be separated from chronic in- 
flammatory lesions of the bone, especially lues. They should be 
excised. 

Sarcoma appears primarily in the cranial bones. Its clinical course 
is similar to that of sarcoma in other portions of the body. Sarcomata 
in this location grow very rapidly and metastasize early. 

Sarcomata of the dura present the clinical picture of brain tumor 



1500 SURGEKY OF THE HEAD 

until the}- perforate the cranium. The former is at first attended with 
brain irritation and later, compression. 

The diagnosis of cranial sarcoma must take into account that pri- 
mary- carcinoma does not occur in this situation. Recognition of the 
nature of the growth rests upon the examination of a microscopical 
section and (by exclusion) on the Rontgenographic findings. The 
treatment consists in complete removal of the growth. The prognosis 
is unfavorable (Wrede^^). 

Lues of the Bones of the Skull. — Luetic lesions of the skull in chil- 
dren are hereditary (Barrier and Feulard^-). In the acquired disease 
the lesions of the skull occur in the tertiary stage. They occur as (1) 
gumma of the periosteum, and (2) gumm<h of the diploe, and are 
often attended with a purulent mixed infection. The clinical course 
of the disease does not differ from that of bone lues elsewhere in the 
body. 

Aside from the constitutional treatment, removal of the diseased 
bone is made imperative because of the danger of accidental mixed 
infection and its extension to the cranial contents. As in all gum- 
mata, removal of the focus is followed by a marked improvement in 
the general condition of the patient. Regeneration follows resection 
of even extensive areas of bone (Hofmeister^^). 

Tuberculosis of the Skull. — Tuberculosis of the bones of the skull is 
not uncommon. It is usually manifested hy the clinical picture of a 
cold ahscess and, though it occurs in the adult, it is more frequently 
found in children. Krause" and Wieting and Raif Effendi^^ furnish 
instructive presentations on the subject. The disease appears in the 
circumscribed and in the infiltrating forms. The possibility of the 
development of the latter form indicates the treatment, which (aside 
from the constitutional care) consists in excision of the diseased bone. 
In extensive processes this may have to be supplemented hy osteoplastic 
repair of the residual defect (see Bone Tuberculosis, p. 441). 

Acute Osteomyelitis of the Skull. — Recognition of the dependence of 
acute osteomyelitis of the cranial bones upon the same factors which 
provoke it in the long bones of the body is due to the work of Lexer.^® 
The clinical course, etc., of the disease is taken up in detail in Part II, 
chap. X. Its especial significance in the skull relates to the danger of 
extension of the infection to the cranial contents. This makes the 
prompt emplojTuent of operative measures of relief imperative. 



SURGERY OF THE SCALP AND CRANIUM 1501 

BIBLIOGRAPHY 

1. Krause. Surg. Oper. ii, N. Y., 1917. 

2. Kauuer. Quoted by v. Bergmanu, iu Handb. der prakt. chir., Stuttgart, 

1913. 

3. V. BuuNS. Quoted by v. Berginann, in Haudb. der prakt. chir., Stuttgart, 

1913. 

4. Stewart. U. S. Army X-ray Manual, N. Y., 1918. 

5. V. Bergmann. Same as No. 2. 
6.- KuTTNER. Same as No. 2. 

7. Gushing. Anns. Surg., Phila., May, 1908. 

8. V. Color und Schjerning. Med. abt. Kgl. Preuss. Kriegminist, 1894. 

9. Ghatelix and De Martel. Med. and Surg. Therapy, iii, N. Y. and 

London, 1918. 

10. BORXHAUPT. Langenbeck's Areh. f. klin. Chir., 1881, xxvi. 

11. Wrede. Verh. d. Deutsch. Chir. Kong., 1912. 

12. Barrier et Feulard. Anns, de dei-m. et syph., 1891, ii. 

13. Hofmeister. v. Bruns' Beitr., xiii. 

14. Krause. Surg, of the Brain, etc., N. Y., 1909. 

15. WiETiXG and Raif Effexdi. Deutsch. Zeitschr. f. Chir., Ixx. 

16. Lexer. See Bibliography, Part II, chap, x, Nos. 29, 30, 36 and 46. 



CHAPTER II 



THE SUKGEKY OF THE BKAIX, ITS MEMBEAXES AND VESSELS 

Cephalocele. — Cephalocele are congenital tumors of the external 
surface of the skull. Thej-^ are covered with skin and communicate 
with the cranial cavity through a defect in the bony wall of the skull 
and appear in its median line either at the occiput or in the region 
of the glabella and root of the nose. Occasional!}', the anomaly pro- 
trudes through the sphenoid or ethmoid bones into the nasal cavities. 

Cephalocele is analogous to 



spina bifida (p. 1422). The 
most frequent form is the hy- 
drocephalocele, which is cov- 
ered with more or less atrophic 
skin, while the arachnoid, the 
bone and dura are absent. 
The last two merge at the base 
of the tumor. Within the 
arachnoid is a layer of brain 
substance surrounding a hol- 
low space filled with cerebro- 
spinal fluid, which communi- 
cates with the ventricles. The 
origin of the protrusion is 
traceable to incomplete clos- 
ure of the cerebrospinal tube. 
The exact anatomical conditions are presented hy Lj'ssenkow,^ Musca- 
tello,^ Berger,^ and others (see bibliography of Spina Bifida, p. 1432). 

The diagnosis of cephalocele is made on the congenital presence of 
the tumor and its t}T)ical location. It is not infrequently associated 
with hj^drocephalus. 

In the few cases which survive after the first few days of life, the 
treatme7it consists in entire removal of the protuberance. The technic 
of the procedure is very similar to that described in connection with 

1502 




Occipital Cephalocele. 



THE SURGERY OF THE BRAIN 



1503 



spina bifida. Lyssenkow^ closes the defect in the skull with a "free 
bone flap." However, if ablation of the protrusion succeeds, the 
defect closes as the child develops. 

Congenital Hydrocephalus. — Congenital hydrocephalus, as distin- 
guished from all other forms of h^'drocephalus, presents a consistent 
and t^'pical clinical picture. The condition consists in a continuous, 
progressive increase of the fluid of the ventricles of the brain — the 
lateral j the third, and the fourth, and at the same time a correspond-- 
ing increase in size of the infantile skull, which, at that period of life, 

has not closed along the 
sutures or at the site of 
the fontanelles. The fluid 
may increase to 1000 or 
even 2000 c.cm. and does 
not show any chemical 
variation from the nor- 
mal. The brain tissue is 
flattened as the result of 
pressure. The condition 
is clearly depicted in 
figure 745. 

As the fluid collects, 
the pressure on the brain 
increases and the child 
dies, usually within th© 
first year of life. At 
times the accumulation of 
fluid ceases spontaneously 
and then suddenly in- 
creases again. Complete 
cessation of the process 
occurs in a considerable number of instances, the ultimate fate of the 
patient being dependent upon the amount of pressure the brain has 
been subjected to. 

The treatment of hydrocephalus is not satisfactory. Repeated 
aspiration, though not dangerous, is only palliative. Recovery has 
occurred in cases in which this has been done (thirty times at intervals 
of five to ten daj^s). Spinal puncture is eflfective only w^hen the for- 
amen o-f Mag-endie is patent. Operative measures destined to estab- 
lish a communication between the ventricles and the subcutaneous 




Fig. 745. — Congenital Hydrocephalus 
(Harlem Hospital case). 



1504 SURGERY OF THE HEAD 

tissues have met with varying success. The technic of Krause,* who 
uses a small silver tube for the purpose, has been followed by relief 
in a number of instances. The work of Kalisher'^ (who furnishes the 
literature) may also be studied to advantage. 

Concussion of the Brain. — Concussion of the brain (commotio cere- 
bri), like that of the spinal cord (p. 1448), has been made the object of 
prolonged investigation for a time, with apparently widely divergent 
conclusions. The details of this need not be entered into here. From 
the ruins of the contest, the facts remain that injury of the brain 
(and skull) is attended with varj-ing degrees of disturbances of con- 
sciousness without the least evidence of an anatomical lesion of the 
brain, and that severe trauma of the brain with contusion, laceration, 
and even extensive loss of substance, may not be attended with modi- 
fication of consciousness. Therefore, one is driven to the inevitable 
conclusion that there is such a thing as pure cerebral concussion 
and that it represents a clinical entity. Its association with cerebral 
contusion and laceration goes without saying, and its clinical differen- 
tiation in this event is not possible at first. Yet its existence must be 
acknowledged, more especially as it has been shown that pure concus- 
sion of the brain may result in death although autopsy may not reveal 
evidence of an anatomical lesion (see Kocher,^ Polis,^ Bouillard,* 
Roncali,^ Miles,^'* Levi^^). V. Bergmann^^ says "The disappearance 
of consciousness while the vital forces persist indicates an arrest of 
the function of the. cortex of the cerebrum. After a fall upon the 
head the patient is incapable of conscious effort, and yet, during this 
night of the senses the medulla oblongata continues to functionate, a 
picture which can be produced only bj^ the disturbance of the function 
of the brain as a vrhole; this is the determining factor which justifies 
the conception that there is such a thing as pure cerebral concussion." 
Experimentally it is possible to produce the picture of commotion 
without producing a discernible lesion of the brain (Kocher^). Just 
what the pathogenesis of cerebral concussion is is not susceptible of 
demonstration for obvious reasons, and one must be content with the 
belief that it is the outcome of the transient effect of trauma upon the 
brain, and this may be circulatory (Fischer^^). 

Injury of the skull causes changes in its configuration in three ways, 
(1) in the sense of concussiaii (commotio cereiri), (2) through the 
collection of endocranial extravasation which occupies space in the 
cranial cavity and interferes with the circulation (compressio cerebri), 



THE SURGERY OP THE BRAIN 1505 

(•3) by the crusliiiig and laceration of the cranial contents (contusio 
cerebri) . 

All of these are due to trauma; theji may exist alone or may be 
associated with one another. A lesioi> may begin as concussion and 
merge into compres-sion, or contusion may occur primarily. Concus- 
sion and compression* are general disturbances of the brain ; contusion 
is localized and is fatal when a vital center (medulla) is involved. 
Concussion and compression are attended with a constant clinical pic- 
ture ; contusion is attended with, spasm, paralysis and disturbances of 
tbe special senses (speech, sight and hearing) and of respiration and 
heart's action. 

The clinical picture of cerebral concussion is expressed in disturb- 
ances of consciousness, which may be mild or severe. The mild forms 
are attended with dizziness, flashes before the eyes, and buzzing in the 
ears; consciousness is entirely lost; there is complete exhaustion, the 
knees give wa}' and the arms are relaxed. The face is pale, the eyes 
fixed and expressionless and the eyelids closed. Respiration is shallow, 
the pulse feeble. This condition is of short duration. The pulse 
improves; this is followed b}^ several deep respirations (vomiting is 
common) ; the patient opens his eyes, stretches his arms and gets up. 
On attempting to stand he is unsteady, grasps his head, complains of 
pain in it and at the site of injury, of buzzing in the ears, soreness of 
the entire body* and of great lassitude. Gradually all the symptoms 
disappear. 

In the severe cases, the patient collapses at the moment of injury and 
remains absolutely motionless, as if in deep sleep. He cannot be 
aroused, reacts to no external stimulus, nor attempts any defensive 
motion. In all cases the pupil reacts to light, and if water is placed 
in the mouth, the patient swallows. The surface of the body is cool, 
the face is shrunken and pale. Respiration is shallow, the pulse small 
and irregular. Feces and urine may be expelled involuntarily. This 
condition may persist for hours and even days. Finally, respiration 
becomes deeper, heart and pulse stronger and fuller, the body regains 
its normal w^armth, and, at the same time, consciousness and the power 
of motion return. The senses are unimpaired and questions are 
answered clearly. As a rule, the above stage of depression is followed 
by a period of exaltation^. The pulse increases in frequency and 
becomes hard, the surface temperature is increased, the face is red, 
the pupils contracted, the eyes bright. The duration of this stage is 
variable. If the sympto7)is continue for several days, the diagnosis of 



1506 SURGERY OF THE HEAD 

pure concussion is excluded. The longer the state of unconsciousneiss 
continues, the more maj- the presence of intracranial injury be 
assumed. Only in- cases in which dangerous sj'mptoms subside rap- 
idly, can the occurrence of extravasation and consequent intracranial 
pressure be excluded; while conversel}', in those cases in which the 
manifestations increase in severity from hour to hour — the pulse 
becoming slower, coma more deep, and respiration intermittent — it is 
fair to assume that further disturbances are present and that these are 
the outcome of continuously increasing intracranial extravasation. 

The treatment of cerebral concussion is that of shock (p. 945). In 
the stage of exaltation morphia may be given subcutaneously. Ritter^* 
advises stimulating return of cerebral function b}' active and passive 
motion of the limbs, dictation of a pleasant theme and mental occupa- 
tion — a sort of educational training. 

Compression of the Brain. — Compression of the brain is a term 
applied to a sjTnptom complex of great clinical importance. It enables 
the surgeoEf to recognize laceration of the middle meningeal artery, 
the presence of a brain tumor, and is of assistance in diagnosticating 
abscess of the brain and a number of acute and inflammatory compli- 
cations of brain injuries. The compressiox is the outcome of limit- 
ing, IMPEDING AND RETARDING THE CIRCULATION OF FRESHLY OXYGENATED 
BLOOD THROUGH THE BRAIN BY LESSENING OF THE SPACE OF THE CRANIAL 

CAVITY (GeigeP^). 

Slowing of the circulation in the brain immediately lessens the 
functional activity. This varies in degree in the several portions of 
the brain. As the circulation becomes gradually slower, the centers 
are affected in sequence as follows, the cortex, the corona radiata, 
the gray matter of the cord, the pons, and, finally, the medulla 
oblongata. Assuming this to be the case, it follows that when certain 
centers are paralyzed, others only begin to be affected. Therefore, 
unconsciousness is combined with convulsions. 

The clinical picture of cerebral compression is presented as follows: 
In uncomplicated cases the causative factor (trauma, sudden effusion 
of blood) is followed by a certain interval before the symptoms 
appear — the so-called free inierval. This distinguishes concussion 
and contusion from pure compression. Attention is calted to a con- 
stant early s^Tnptom of cerebral compression by Bordley and Gushing,^® 
who state that the visual field for blue is smaller than it is for red, 
and for white is normal. After the pressure is relieved normal 
conditions are reestablished. 



THE SUKGERY OF THE BRAIN 1507 

Of all the functions, that of consciousness is most rapidly 
LOST and does not return until the circulation is fully reestablished. 
As a rule, however, a ease of pure compression is rarely encountered ; 
most of them are associated with concussion and contusion of the 
cranial contents, so that the study of comjiression by itself is of neces- 
sity based on experimental observations. These show that the I'Res- 

SUKE symptoms DEVELOP IN REGULAR SEQUENCE AND, IN A GENERAL 
WAY, TUE SYMPTOMS APPEAR IN ACCORD WITH THE DEGREE OF PRESSURE. 

The onset is attended with restlessness, groaning, nausea and vomit- 
ing, followed by unconsciousness, stupor and coma. Slowing of the 

PULSE OCCURS SIMULTANEOUSLY WITH STUPOR, AND IS ONE OF THE MOST 
CONSTANT AND CLEARLY MARKED SYMPTOMS OF CEREBRAL COMPRESSION. 

When the pressure exceeds a certain degree the pu\?e becomes rapid. 
In the transitional stage the heretofore regular, lull pulse becomes 
small and intermittent. This is ascribed to irritation of the vagus in 
the first instance and its paralysis in the second. The vasomotor center 
presents a similar condition of affairs ; thus the blood pressure at first 
rises and later falls (v. Bergmann^^). Resyiration, primarily super- 
ficial, soon becomes slow and often stertorous. As is the case with the 
heart, when the compression of the brain, is carried beyond a certain 
point, respiration becomes again irregular, with long intervals of 
absence of respiratory effort, until these cease entirely. 

The symptomatology of cerehral compression may be divided into 
two stages, that of irritation attended with cephalalgia, vomiting, 
restlessness, congestive redness of the face, contracted pupil, develop- 
ment of choked disk, increased blood pressure and slowing of the pulse ; 
and paralysis, in which unconsciousness merges into stupor and 
coma, respiration becomes stertorous and intermittent, the pulse rate 
greatly increases, and the urine and feces are expelled involuntarily. 
Presently, the respiration becomes of the Chejoie-Stokes variety and 
soon ceases entirely, while the heart continues its laborious activity 
for a few moments longer. The severity of the pathological changes 
is indicated by the ophthalmoscopic examination, which reveals swell- 
ing of the optic nerve, i. e., choked disk. The precise pathology of 
cerebral compression is presented in detail by Tilmann,^^ who reviews 
the work of a number of other observers. There can be no doubt that 
increased blood pressure in the arteries of the brain is conveyed to the 
cerebrospinal fluid, which is caused to flow into the spinal canal, thus 
affordmg, as far as possible, the necessary space for the increased 
quantity of blood in the cranial cavity. As long as this balance is 



1508 SURGERY OF THE HEAD 

maintained cerebral compression does not occur; beyond certain 
phA'siological limitations, however, the clinical picture indicative of 
brain pressure begins to develop. This is equally applicable to lessen- 
ing- of the space in the cranial cavity from other causes which may be 
acute or chranic. 

Acute cerebral campressio-n occurs in connection with depressed 
fractures and extracerebral hemorrhage and acute inflammatory 
processes (meningitis purulenta), acute brain abscess, epidemic cere- 
bral meningitis, and meningitis serosa. 

Chronic cerebral compression develops from congenital and acquired 
chronic hj'drocephalus, chronic brain abscess, cysts and parasites of 
the brain, and from premature closure of the sutures and fontanelles 
of the skull. 

Tuberculous meningitis occupies a place between acute and chronic 
compression. 

In a general way, it may be said that the more sudden the compres- 
sion, the more acute are the sjTnptoms. Acute compression is practi- 
cally limited to endocranial traumatic extravasation of blood and 
EXTENSIVE DEPRESSED FRACTURES OF THE SKULL. The latter are more 
important in connection with localized pressure than with general com- 
pression. To these primary causative factors must be added the effect 
of the accumulation of the products of inflammation in the form of 
acute or chronic abscesses. 

The course and outcome of cerebral compression are determined by 
the character of the causative factor. Much depends upon whether 
the compressive agent is subject to modification in its relationship to 
the capacity of the cranial cavity, i. e., whether the encroachment is 
progressive or whether it permits of resumption of the normal. In 
bone pressure compression progresses, unless relieved by operative 
measures. An extravasation of blood may be arrested by spontaneous 
closure of the vessel. 

Purulent exudates go relentlessly on. It is, therefore, of the 

GREATEST IMPORTANCE TO DETERMINE WHETHER THE PRESSURE SYMP- 
TOMS ARE INCREASING OR DECREASING. Next in importance is the 
LENGTH OF TIME THE COMPRESSION HAS EXISTED. Even Severe prcssure 
of short durati-on is soon recovered from. Persistence of the pressure 
is no less dangerous than its degree, on the ground that slowing of the 
circulation is followed by transudation of the fluid constituents of the 
blood and the development of cerebral edema. In this event, regres- 
sion of the s;^Tnptoms of compression is very slow and may never occur. 



THE SURGERY OF THE BRAIN 1509 

The treatment of cerebral compression is aimed at its cause. This 
means the operative elevation of the depressed bone and the removal 
of extravasated blood, the inflammatory exudate, the tumor and the 
excessive amount of cerebrospinal fluid. This is attained by two 

METHODS, FIRST, BY PUNCTURING OR DRAINING THE VENTRICLES OR THE 
SUBARACHNOID SPACES AT THE LUMBAR REGION OF THE SPINE, AND 
SECOND, BY OPENING THE SKULL. 

Reduction in the quantity of the cerehrospinal fluid is indicated in 
acute hydrocephalus of tuberculous meningitis, acute serous meningitis 
and chronic acquired hydrocephalus. 

The methods of reducing the quantity of cerebrospinal fluid are : 

1. Lumbar puncture and lumbar drainage. 

2. Puncture of the ventricle, cerebral puncture and ventricular 
drainage. 

3. Decompressive trephining, 

(1) For lumbar puncture see Part IX, chapter i, especially the 
bibliography. 

(2) Puncture of the lateral ventricle may be accomplished from in 
front (v. Bergmann^') or through the parietal bone (Keen^^). Per- 
manent drainage has been attained by Keen,^^ Krause,* and others by 
inserting glass or metal cannulas through small trephine openings 
into the ventricle and establishing communication with the subapo- 
neurotic space (see also Payr,^° Fowler^^). 

(3) Decompressive trephining is employed when the compressing 
agent cannot be removed, i. e., not localized and inoperable tumors. 
Its great disadvantage lies in the sequential prolapse of the brain 
(hernia cerebri) and the trauma to the brain tissue. The latter argues 
for the selection of a site over an unimportant sector of the brain. 

Injury of the Intracranial Vessels. — Injury of the intracranial vessels 
is of the greatest practical importance in connection with the middle 
meningeal artery. The artery is injured by penetrating instruments 
and by projectiles. In the majority of cases, however, blunt force 
produces more or less extensive bone injury, as the result of which the 
vessel is torn. It is most frequently lacerated as the bone is broken. 
This is more likelj' to occur when the artery lies in a canal than in a 
groove. The artery has been torn without the bone being fractured, 
i. e., as the result of temporary deformation of the skull. Injury to 
the vessel by contre coup is of especial interest and its possibility must 
be borne in mind in the diagnosir*.. Hovanian^^ has collected thirteen 



1510 



SURGERY OF THE HEAD 




Fig. 746. — A, Compound Fracture of Cranium with Depression. 
Fracture of bones of face; extradural clot from rupture of middle meningeal 
artery. 




Fig. 746. — B, Horizontal Section of A. 
Depression of bone a-b; Extradural clot c; Laceration of brain substance with 
intracerebral clot D; same condition (e) produced by contra coup. _ Punctate 
hemorrhages and minute lacerations at numerous points, characteristic of con- 
tusion of the brain. 



THE SURGERY OF THE BRAIN K'll 

cases af this sort. The luechauisni of laceration of the artery is encom- 
passed in the "mechanics of fracture of the skull" (p. 1489). 

The immediate elfect of iaceration of the artery is bleeding which, 
as it cannot escape from the cranial cavity, is followed by the accumu- 
lation of blood (hematoma) within it, unless tli-e injury occurs in con- 
nection with a compound fracture. The result of the formation of 
the hematoma is progressive compression of the brain. In most 
instances the extravasation' of the blood is extradural. Occasionally, 
when the dura is torn, the blood is effused subdurally. As the extra- 
dural extravasation* progresses the dura is elevated from the bone 
(zo7ie dccollable of Marchant^^). Spontaneous arrest of bleeding, the 
result of increased intracranial pressure, occurs when about 200 gms. 
of effused blood has collected (Kronlein^*) ; clinical manifestations 
develop when 60 gms. of blood have been effused (v. Bergmann^-) . The 
hematoma is usually situated in the middle fossa of the cranium. The 
posterior branch of the vessel is rarely torn (Kronlein-*). The mor- 
phology of the effused blood has been studied by Wiesmann.^^ 

The clinical manifestations of intracranial hematoma are expressed 
in the typical symptom complex of increasing cerebral compression, 
usually preceded by a free interval of several hours. The picture of 
general compression is not infrequently preceded by the gradual 
development of contractile hemiplegia, especially when the hematoma 
is still circumscribed. The claim that the pupil on the injured side is 
always dilated and that on the other contracted has not been 
substantiated. 

The diagnosis, in practice, is not without its difficulties. These are 
embraced in the fact that most cases at first display the symptoms of 
concussion or contusion, which may be so severe that there is not time 
for them to subside before the stage of compression begins to become 
manifest. This is especially true, as focal symptoms invariably occur 
late in the symptomatology of head injuries and, not infrequently, 
slowing of the pulse, due to irritation of the vagus center, occurs early. 
When a head injury occurs during alcoholic intoxication, the picture is 
still more obscure, to which may be added the difficulties attendant 
upon a sudden apoplexy which causes the patient to fall and strike 
the head. In doubtful cases, brain puncture gives valuable informa- 
tion. When a fracture is present, much reliance may be placed on the 
radiographic findings (p. 1494). 

The prognosis, when the pressure is not relieved, is uniformly 
unfavorable. 



1512 SURGERY OF THE HEAD 

The task of treatment consists in relief op the cerebral compres- 
sion BY REMOVAL OF THE HEMATOMA AND PREVENTION OF FARTHER 

ACCUMULATION OF BLOOD. In OPEN INJURIES this is readily accom- 
plished by opening the wound in the skull, wiping out the clot, and 
tying the bleeding point or points. 

In closed injuries the skull must be opened. This should be accom- 
plished over the main trunk of the middle meningeal artery. As it is 
rarely certain which of the branches of the artery is torn, the osteo- 
plastic trephining of Krause^ is largely practiced for the purpose. 
The technic is the same as that used for exposure of the ganglion of 
Gasser (p. 1626). The exposure achieved in this way renders the artery 
'readily accessible, permits of complete removal of the hematoma, of 
ligature of the torn vessel, and makes satisfactory repair of the skull 
possible. The division of the main trunk of the artery into its two 
primary branches corresponds to a point 4 cm. behind the zygomatic 
process of the frontal bone on a line drawn from the supra-orbital 
ridge backward and parallel to the horizontal base line of the skull 
(Kronlein^*). 

When the extravasated blood is removed the clinical picture immedi- 
ately changes, so that not infrequently return to normal occurs simul- 
taneously with recovery from narcosis. Few surgical efforts at relief 
are crowned with a more brilliant outcome than is the successful 
achievement of the abolition of cerebral compression in cases of this 
sort. 

Injuries of the Cranial Sinuses. — Injuries of the cranial sinuses of 
surgical importance are those involving the longitudinal, the lateral, 
and the junction of the two — the torcular Herophili. They occur 
•most frequently in connection with fracture of the vault of the skull, 
in which the bony structure breaks and tears the sinus or, more com- 
monly, a splinter of the internal table perforates one of the sinuses. 
A similar condition of affairs occurs in connection with punctured or 
gunshot wounds, in which either a splinter of bone or the projectile 
traumatizes a sinus. It is not improbable that a sinus may be torn 
when blunt force deforms the skull without the occurrence of fracture ; 
to these belong a certain number of the cases of intracranial hemor- 
rhage of birth (see Wharton^®). 

In open injuries of a sinus the symptoms are self evident ; in those 
in which the cranium is intact the picture of cerebral compression is 
presented. Diagnosis is possible only in open injuries. 

The surgical treatment, i. e., the arrest of bleeding, is also limited 



THE SURGERY OF THE BRAIN 1513 

to the open injuries and consists in exposure and tamponade of the 
sinus. Double ligature of a completely torn sinus is not impracticable. 
Trephining for the relief of cerebral compression in the closed cases 
would have to be ba-sed on localization of the hematoma by brain punc- 
ture and on a consideration of the manner in which the injury was 
received. The treatment of sinus pericranii is taken up on page 1484. 

Injuries of the vessels of the pia (subdural hemorrhage) are attended 
with bleeding into the meshes of the pia mater. The extravasations are 
widely varied in extent, ranging from a minute ecchymosis to a hema- 
toma covering an entire cerebral hemisphere. The condition not infre- 
quently occurs in the newborn in connection with forceps deliveries. 
In these instances the clinical picture closely resembles the asphyxia 
of the newborn. Debraigne-^ advises the employment of lumbar punc- 
ture, which clears up the diagnosis. Gushing-^ has employed bilateral 
subtemporal decompression for relief of the pressure. Of nine cases, 
four recovered. 

Traumatic suhdural hematoma is so often associated with contusion 
and laceration of the brain that the presentation of a distinctive clin- 
ical picture is not to be expected. The symptom complex is very 
similar to that of extradural hemorrhage. Henschen^*^ divides the 
condition into diffuse and circumscrihed hematomata. The latter may 
be situated anywhere in the brain. Those at the cerebellum and 
medulla are rapidly fatal. 

Perhaps the onl}^ distinctive diagnostic phenomenon is that empha- 
sized by Oppenheim,^" namely, that the evidence of cerebral involve- 
ment does not become manifest until the fifth or seventh day after the 
injury''. The lesion may be attended with the presence of blood in the 
fluid obtained by lumbar puncture. In a general way the prognosis 
of subdural hemorrhage is better than that of the extradural; the 
former is more likely to be absorbed. 

The treatment is indicated by the gradual domination of the clinical 
picture of cerebral compression. It consists in preliminary cerebral 
puncture and, when the site of the bleeding is determined, in trephin- 
ing and removing the clot. Brion^^ calls attention to the fact that 
removal of a certain portion of the extravasated blood is followed by 
accelerated absorption of the remainder. 

Traumatic arteriovenous aneurism, of the internal carotid artery 
(sinus cavemosis) results from fracture of the base of the skull and is 
caused by penetrating and gunshot wounds of the vessel in this 
situation. 



1514 SURGERY OF THE HEAD 

In fully developed cases the symptoms are characteristic. They 
consist in a marked exaphthalmos, in which the eyeball distinctly pul- 
sates, and a clearly defined hmit is present. The eyelids are edema- 
tous and the veins about the orbital cavity are dilated. Examination, 
of the fundus reveals choked disk and the presence of dilated veins. 
The various motor nerves of the muscles of the ej'eball are progres- 
sively paralyzed and the fifth nerve is often affected. The patient com- 
plains of headache and is constantly conscious of buzzing and roaring 
in the ears. Compression of the carotid in the neck excludes the 
symptoms, which return when the pressure is released. 

The treatment is not very satisfactory. Digital compression has 
been employed with lessening of the symptoms. Ligature of the com- 
mon carotid is justified. In this connection the monograph of Becker^^ 
is instructive. 

The operative treatment of apoplexia sanguinea has- long fascinated 
the imjagination of the surgeon. In 1890, Horsley^^ proposed to tie 
the carotid in cases of this sort. Chipault,^* on theoretical grounds, 
suggests that in individuals who have already had an attack of apo- 
plexy, the carotid may be tied as a preventive measure, and in persons 
who have a mild primary attack, the clot may be removed and the 
cavity tamponed. Marion^^ regards the first proposition as objection- 
able, on the ground that the operation has no influence on the causative 
arterial disease, and fears that the identification of the focus is too 
uncertain to justify the second. More recently, Franke^^ and Milli- 
gan^^ have reported cases in which enucleation of the clot has been 
followed by recovery. Both surgeons operated during rather severe 
symptoms of compression. On the other hand, Marion^^ considers the 
operation justified only when localization of the lesion is possible. 

Injuries of the <^ranial nerves in their course in the skull occur in 
connection with severe trauma of the cranium as a whole, usually the 
base. However, at times, a nerve in this situation is directly injured 
in jperf orating and gunshot wounds. As a rule, paralysis of a cranial 
nerve occurs at the time the trauma is inflicted, i. e., by crushing or 
laceration by a splinter of bone; occasionally, late paralysis results 
from pressure of reparative callus. In primary injuries the prognosis 
is good, the nerve usually regenerating. When the paralysis occurs 
late, return of function does not, as a rule, occur. The clinical picture 
is that of paralysis of the part supplied by the injured nerve (see 
Surgery of the Nerves, p. 574). Special presentations on the subject 



THE SURGERY OF THE BRAIN 1515 

are submitted by v. Bruns,^^ Stephanoff,^'' Bonner,*" Cantonnet,*^ 
Ferron/- Clairmout," and Honusa.*^ 

BIBLIOGRAPHY 

1. Lyssenkow. Moscow Diss., 1896. 

2. MuscATELLO. Arcli. f. klin. Cliir., 1894. 

3. Bergek. Rev. de chir., 1890, T. x. 

4. Krausb. Surgery of the Brain, etc., N. Y., 1909. 

5. Kalisher. Handb. d. Neurol., Berlin, 1911, iii, with lit. 

6. KociiER. Deutscli. Zeitschr. f. Chir., 1893, xxxv. 

7. PoLis. Rev. de la chir., 1894, Avril et Aout. 

8. BouiLLARD. Gas. des hospitaux, 1892, No. 54. 

9. RoNCALi. Chipault's Trav. de neurol. chir., 1900. 

10. Miles. Med. Chronicle, 1892. 

11. Levi. Rev. generate de path, de guerre, No. 2, Vigot, 1918. 

12. V. Bergmann, in Handb. d. prakt. Chir. i, Stuttgart, 1913. 

13. Fischer. V. Volkmann's klin. Vortr., No. 27. 

14. RiTTER. Zeitschr. f. iirtz. Fortbild., 1910, No. 2. 

15. Geigel. Stuttgart, 1890. 

16. BORDLEY and Gushing. Same as No. 12. 

17. v. Bergmann. Arb. a. d. chir. Klinik der Univ., Berlin, 1886, T. i. 

18. TiLMANN. Langenbeck's Arch., 1912, xcviii. 

19. Keen. Phila. Med. News, 1890. 

20. Payr. Deutsch. med. Woch., 1912, No. 6. 

21. Fovt^LER. Anns. Surg., March, 1919. 

22. HovANiAN. These de Paris, 1902. 

23. Marchant. Des ei^anohments sang, introcran. consec. au traum, Paris, 

1881. 

24. Kroxlein. v. Bruns' Beitr. xiii; also Deutsch. Zeitsch. f. Chir. xxiii. 

25. Wiesmann. Handb. d. prakt. Chir. iii, 1907. 

26. Wharton. Anns. Surg., 1901, ii. 

27. Debraigne. See Dutrey, These de Paris, 1905. 

28. Gushing. Phila. Med. Jr., Jan. 20, 1900. 

29. Henschen. Zentrbl. f. Chir., 1912, No. 30. 

30. Oppenheim. Berlin klin. Woch., 1897. 

31. BniON. Diss. Strasbourg, 1896. 

32. Becker. Verh. d. deutsch. Gesel. f. Chir., 1907. 

33. HoRSLEY. Quoted by v. Bergnnann in No. 12. 

34. Chipault. Trav.. de neurol. chir., 1899, T. xi. 

35. Marion. Chir. du systeme nerveux, Paris, 1905. 

36. Franke. Deutsch. med. Woch., 1910, No. 30. 

37. MiLLiGAN. Jr. Am. Assoc, 1911, No. 24. 

38. v. Bruns. V. Bruns' Beitr., 1906, xxxviii. 

39. Stephanopf. These de Montpellier, 1900. 

40. Bonnet. These de Bordeaux, 1907. 

41. Cantonnet. Rev. d. chir., 1908. 

42. Ferron. Arch. prov. de chir., 1907-8. 

43. Clairmont. Mitteil a. d. Grenzgeb., 1909, xix. 

44. HoNUSA. Mitteil a. d. Grenzgeb., 1912, xxiv, 



CHAPTER III 

CONTUSIONS AND WOUNDS OF THE BRAIN 

Excluding the rare, direct invasion of the cranial contents through 
the sphenoidal fissure, injuries of the brain take place indirectly 
through the medium of the bones of the cranium. This is brought 
about by external violence, the outcome of either a change of con- 
formation of the skull (and its reassumption of the normal) or of a 
fracture or wound of the bones. However, even punctured and lace- 
rated wounds are attended with more or less contusion, of the brain. 
The latter is in accord with the hydrodynamic laws and their influence 
upon the soft consistency of the brain substance, which easily transmits 
force in all directions, and, therefore, also in a direction perpendicular 
to that of the inflicted violence. For practical purposes, traumatic 
lesions of the brain may be divided into contusion of the brain, in. 
which the solution of continuity does not communicate with the air, 
and wounds of the hrain, i. e., injuries occcurring in connection with 
open wounds in the covering of the brain and involving the brain 
itself, the path of the trauma communicating with the open air. 

Contusions of the Brain. — Contusions of the brain present wide dif- 
ferences as regards extent, number and location. They may consist 
of small punctuate areas of contusion, or may be the size of a cherry or 
a goose egg. An entire lobe may be crushed. 

The localization of brain contusions is extremely varied. At the 
first glance they appear to be subject to no rule, yet are found to occur 
in a certain regular order, if considered not by themselves, but in con- 
nection with the fractures of the skull which so frequently accompany 
them. The mechanism of the production of contusions is the same 
AS that concerned in the production of injuries of the skull and 

THE brain at the SAME TIME AND MAY BE FORMULATED AS FOLLOWS : 

1. In bursting fractures of the skull the accompanying contusions 
of the brain generally lie in the direction of the inflicting violence, 
being usually more severe at the poles of the line of force, i. e., at 
those portions of the brain which receive the direct impact at the time 

1516 



CONTUSIONS AND WOUNDS OF THE BRAIN 1517 

the spheroid becomes fl-attened. Thus, in lomjiludinal fractures of the 
base the frontal lobe of the cerebrum and the cerebellum are contused ; 
ill transverse fractures, both temporal lobes; in oblique fractures, the 
frontal lobe of one hemisphere and the parietal lobe of the other are 
contused. Deviation from this general law is often found, owing to 
the peculiarities of the cranial spheroid and of the brain substance 
itself (Kronlein^). 

2. In localized comminuted fractures of the skull the principal 
contusions appear immediately beneath the site of injury. 

3. The occurrence of multiple foci of contusions is explainable on 
the ground of the semifluid consistence of the brain and the abundance 
of its t)lood and cerebrospinal fluid. According to hydrod;yaiamic laws, 
any violence affecting this mass at one point cam be transmitted in 
directions other than the line of force, producing solution of continuity 
of tissue. Relatively, the walls of the ventricles appear to be most 
frequently the site of contusion w^hen. the direction of the violence 
coincides with the major axis of the cavities, i. e., in connection with 
longitudinal fractures. 

4. Where there are deep lacerations of brain substance, they are to 
be considered the result of bursting fractures in the direction of the 
inflicting violence. 

Laceration of the meninges may occur in injuries of the skull inde- 
pendently of contusion. In these instances the solution of continuity 
of the dura or piais due to the same force that produces a simultaneous 
contusion at another portion of the brain. 

The course of contusions of the brain which communicate with the 
air is similar to that of wounds in general, and is of course most seri- 
ously influenced by infection (p. 1526). In those that do not communi- 
cate with the air the changes are those common to subcutaneous con- 
tusions in general. In the brain the connective tissue elements of the 
pia and the vessels play almost the only part, while the neuroglia has 
an insignificant one. Regeneration of nerve cells, and probably of 
nerve fibers, does not occur. This much is certain, extensive trau- 
matic DEFECTS OF THE BRAIN ARE CLOSED BY THE DEVELOPMENT OF SCAR 

TISSUE (Ziegler,- Tschistowitsch^). This scar may be solid and firm 
or may show a cystoid structure, the cavities of which are filled with a 
yellow fluid (cholesterin). 

Brief allusion may be made to rupture of tlie brain occurring in 
children!, the result of injurs^ The condition is characterized by a 
distinct tear in the brain extending into the ventricle. This heals and 



1518 SURGERY OF THE HEAD 

then forms a cyst of, at times, considerable magnitude {porencephalia 
traumatica). These injuries and the sequential cyst formation are 
responsible for so-called meningocele spuria, or cephalohydrocele trau- 
matica, which bears considerable resemblance to congenital cephalocele 
described on page 1502 (Rahm^). 

The processes of repair folloudng contusion of the irain have a bear- 
ing on the present day conception as to the justification of operative 
efforts destined to afford relief from the unfortunate sequelae conse- 
quent to this class of injury. Aside from the protracted process of 
repair which results in sca^" formation in accord with the degree of tis- 
sue destruction, there are cases in which, during the course of years, a 
degeneration of the nervous elements takes place which extends far 
beyond the limits of the original injury. This encephalonialacia is 
ascribable to a progressive degeneration of the small blood vessels, 
Brought about by circulatory disturbances in the vicinity of the area 
of contusion. The process may (after a prolonged latent period) 
extend over several lobes of the brain and destroy the host (v. Mona- 
kow^). The influence that these histological changes have upon vari- 
ous psychoses, cortical epilepsy, cerebral tubercle, glioma, sarcama, 
(etc., cannot be disregarded (Kiittner°). 

Wounds of the Brain. — Wounds of the" brain may be classified as 
contused, punctured, and lacerated. In distinction from those just dis- 
cussed, they possess one common feature, namely, that the causative 
violence has divided all the coverings of the brain, so that there is a path 
from the external surface of the body to the central organ of sufficient 
size to allow the escape of destroyed brain substance on the one hand, 
and the entrance of air and infectious germs on the other. This expos- 
ure of the brain lesion is a factor of such great importance that a 
distinction between contusion and wounds of the brain seems justifiable. 

Wounds of the brain occur as the result of violence from blunt or 
sharp objects. Both mechanisms may occur at the same time. In fact, 
as a result of the involvement of the cranial bones, the provocative 
force may be entirely altered in its transmission from without inward, 
so that blunt force may lead to a brain injurj^ which possesses the 
characteristics of a punctured or incised wound, while violence from 
a sharp object may lead to a contused wound. The nature of these 
forces and their effect are in accord with the mechanism of the produc- 
tion of fractures of the skull (p. 1489). 

The course of a wound of the brain does not depend so much upon 
whether it bears the character of a punctured or lacerated wound, as 



CONTUSIONS AND WOUNDS OF THE BRAIN 1519 

upon whether infection has or has not taken place. If infection does 
not occur, the subsequent course of wounds of the brain is the same 
as that of contusions of the brain. The course of infected wounds is 
taken up below. 

Contused wounds of the brain occur in connection with compound 
fractures of the skull, especially those caused by projectiles. In the 
latter instance the trauma to the brain tissue is likely to be great and 
the sequelae, previously discussed, most frequently develop. This is 
especially important in connection with gunshot wounds of the brain 
produced in civil life by small arms (Flobert rifles, etc.). 

Punctured wounds are of import because of the danger of infec- 
tion and the liability that portions of the causative instrument may 
be left in situ. When infection does not occur, it frequently happens 
that objects of this sort become encysted and do not give rise to any 
disturbances. 

Lacerated wounds of the brain do not present any determining re- 
gional peculiarity. They are often produced by sabers, cleavers, heavy 
knives, etc., and are less likely to be infected than the contused and 
punctured. However, as already stated, the causative force often 
produces contusion of the adjacent portions of the braiti tissue, es- 
pecially when the bone is splintered. 

Infection of icounds of ike hrain is the outcome of the entrance of 
pyogenic organisms of a certain virulence into a field receptive for 
colonization. Unfortunately, wounds of the hrain are particularly 
susceptihle to infection. This is shown b}' the fact that what appears 
to be a simple contusion of the brain is often followed by the develop- 
ment of infection. In such cases pyogenic organisms are conveyed to 
the site of the lesion through the circulation; suppuration is here a 
metastatic process. However, this is exceptional, and as a rule there is 
a more direct invasion of the excitants at the site of the injury. If 
the traumatized area is thus invaded, suppurative inflammation de- 
velops. This entire process runs the anatomical and clinical course 
of encephalomeningitis. If the inflammation remains localized and 
the pus readily escapes through the existing wound in the bone and 
soft parts, repair may still take place by granulation and cicatriza- 
tion. If, however, the pus does not find an avenue of egress and is 
retained in the injured area, an acute traumatic cortical abscess is 
formed. Frequentlj', however, purulent inflammation is not restricted 
to the injured area, but, from the very beginning, exhibits a decidedly 
progressive character, spreading rapidly in the loosely meshed connec- 



1520 SURGERY OF THE HEAD 

tive tissue of the arachnoid. The pial tissues and the subarachnoid 
spaces are soon filled with exudate extending along the vessels and 
invading the cerebral cortex. Spreading inflammation of this sort 
rapidly ends the life of the host. The organisms concerned in this 
process are usually the streptococcus pyogenes and the various pyogenic 
staphylococci. 

The symptoms of hrain i^ijuries are usually those indicating the 
destruction of localized areas of cerebral tissue and the diagnosis 
rests upon a sufficient knowledge of the localization of the physiologi- 
cal functions of the brain, as far as they are determined by experi- 
mental and clinical observations. "While the history of the case and 
the location of the injury should be, and are, helpful in diagnosticat- 
ing the site of a traumatic brain lesion, a conclusion in this connection 
is often rendered difficult bj^ the following factors : 

1. Very frequently contusions and wounds of the brain are asso- 
ciated with manifestations of concussion and compression which com- 
pletely obscure the focal symptoms. 

2. In many instances there is more than one traumatized area in 
the brain. 

3 The areas of injurj^, particularly in contusions, are often very 
extensive and are combined with intrameningeal hemorrhage, hemor- 
rhage into the cortex and into the ventricles. 

4. A number of localized injuries involve portions of the brain 
and do not give rise to symptoms. 

5. While, until now, only symptoms of primary localized injury 
produced by mechanical causes have been considered, it is necessary 
to take into account that frequently symptoms of infection rapidly 
appear. These are the expression of purulent meningitis and en- 
cephalitis and indicate the site of the lesion. More frequently, how- 
ever, as a result of these progressive changes, the nutrition and circu- 
lation in the entire brain are so changed that a topical diagnosis is 
impossible. 

Cerebral Localization (After v. Monakow^). — The motor zone encom- 
passes the cerebral cortex of the anterior central convolution, a part 
of the posterior central convolution, the gyrus centralis, the lohulus 
paracentralis, the operculum and the root of the third frontal convo- 
lution. 

The central convolutions contain three cortical zones: 
1. The leg region, in the upper one fourth of both central convo- 
lutions (including the paracentral lobule). 



CONTUSIONS AND WOUNDS OP THE BRAIN 1521 

2. The arm region, in the middle two fourths. 

3 The head region, in the lower one fourth (including the oper- 
culum, central fissure, and the root of the third frontal convolution). 

Each of these three regions include the various foci for excitation of 
definite groups of muscles. 




Fig. 747. — Cerebral Localization. 



The posterior central convolution is probably concerned in sensar 
tion. On the other hand, there is no doubt that a portion of the 
frontal lobe in front of the anterior central convolution, certain sec- 
tors of the occipital lobe (motion of the eyeballs), and the temporo- 
sphenoidal lobe (movements of the ear) are motor. 



1522 SURGERY OF THE HEAD 

For contusions and wounds within the motor zone, the following laws may 
be established for diagnostic purposes : 

1. Cortical lesions alone are rare. As a rule, the injury extends to the 
white substance beneath. 

2. Very small cortical lesions may occur without symptoms, if an unim- 
portant area is involved. 

3. Per contra, a slight lesion may produce a characteristic symptom com- 
plex, when located in an important focal area. 

4. Total destniction of both central convolutions always causes hemiplegia 
on the opposite side of the body. 

5. Muscle sense is imj^aired when the parietal lobe is injured; tactile sense 
without disturbance of sensation occurs in lesions limited to the posterior 
central convolution. 

6. Partial destruction of both central convolutions is common and char- 
acterized by monoplegias and monospasms. 

These monoplegias are either pure, i. e., paralysis of an isolated 
part of the body (leg, arm, head), or associated, i. e., paralysis of 
greater or lesser areas of two regions simultaneously; for instance, 
arm and leg {'brachiocrwral monoplegia) or arm and head (hrachio- 
facial monoplegia) ; never, however, leg and head without the arm, 
because the head and the leg are separated by the arm center. 

Among the pure monoplegias, that of the leg is observed in lesions 
of the upper one fourth of the anterior and also of the posterior central 
convolution or of the paracentral lotule. In mechanical irritation 
(splinters of bone), monoplegia is preceded by a period in which the 
leg is contractured and may exhibit spasm. A cortical lesion of this 
sort may give origin to jacksonian epilepsy. 

Monoplegia of the arm is the result of a lesion of the middle half 
of the central convolutions, including the cortex of the contiguous 
sulci. Traumatic paralysis may be preceded by clonic spasm, and 
jacksonian epilepsy may take its origin from this location. 

Isolated cortical facial paralysis does not occur. Lesions in the 
head region (facial and hypoglossal regions) are" attended with asso- 
ciated faciohrachial or fadoUngual monoplegia. In so-called facial 
monoplegia, the lower facial muscles are usually affected, the upper 
escaping. In faciohrachial monoplegia the muscles of the tongue 
and forearm are usually affected. 

The parietal convolutions are believed to be concerned in the higher 
psychic functions, and the center of this region, in muscle sense. 
Lesions in this situation may be responsible for volitional ataxia and 
for sensory jacksonian epilepsy. 

Lesions of the occipital convolutions are attended with hemi-anopsia 
(lateral). This is due to the decussation of the optic nerve fibers in 



CONTUSIONS AND WOUNDS OF THE BRAIN 1523 

the cliiasm. Tlic reji^ion ui' tlio calcariiie fissure is espocially con- 
ceriiod in this couneetion. Complete hcnii-anopsia (Iiemi-ainblyopia, 
hemi-achromatopsis) occurs in lesions of both occipital lobes. Corti- 
cal lesions of these lobes are at times attended with optic aphasia. 

The functions of the frontal canvolutions, aside from the posterior 
ends of the first and second (motor) and the posterior half of the 
third — which is concerned in speech — are not clearly understood. 
They would seem to be concerned in the so-called intellect. In tumors 
of the frontal lobes, a form of ataxia {frontal aiavcia) resembling that 
attendant upon lesions of the cerebellum has been observed (Jastro- 
witz, Witzelsucht, L. Bruns, Liepmann, Hartmann, see v. Monakow'"'). 

The speech center encompasses the cortex of the region around the 
Sylvian fossa, i. e., the posterior half of the third frontal (Broca's) 
canvolution, the entire island of Beil, the first temporal convolution, 
including the cortex of the entire Sylvian fissure to the supramarginal 
gyrus. Lesions in this region produce the disturbances designated by 
the term aphasia. In right handed persons, the left side of the region 
stated, and in left handed persons, the right side functionates in this 
connection. 

Motor aphasia consists in an inability to express ordinary language 
or to repeat spoken language. This is due to a lesion of the (left) 
third frontal convolution and is often associated with agraphia (in- 
abilitj^ to write). 

Sensory aphasia (word deafness) consists in inability to understand 
spoken language. This is caused by a lesion in the (left) first tempo- 
ral convolution and is often associated with alexia (inability to under- 
stand printed words), rarely with agraphia, although, paraphasia is 
present. 

Complete aphasia occurs when motor and sensory aphasia coexist. 
It is easy to understand that a severe lesion of the third frontal con- 
volution would extend to the contiguous structures of the motor region 
and that the head center would be likely to be involved. As a matter 
of fact, motor aphasia is often attended with faciohrachial and facio- 
lingual monoplegia and even with hemiplegia. When lesions of this 
sort are irritative in character, jacksonian epilepsy is often present. 

In lesions of the upper temporal convolution (including the gyrus 
supramarginalis) sensory aphasia may be associated with disturhances 
of sensation, especially of muscle sense on the opposite side of the body 
when the parietal lobe is involved ; or it is combined with hemi-anopsia 
when the deeply located optic fibers (en route) are involved. 



1524 SURGERY OF THE HEAD 

In the insula itself small lesions may not give rise to any disturb- 
ances, while larger ones produce motor or sensorj' aphasia, depending 
on the center to which they are nearest. 

Lesions in the internal capsule are attended with symptoms in 
accord with the extent of the destruction of fibers, varying from 
complete to partial hemiplegia and hemi-anesthe^ia. Pure isolated 
monoplegia does not occur. 

Lesions of the corpus striatum and the lenticular nucleus only pro- 
duce symptoms wheii the internal capsule is involved. 

Lesions of the optic thalamus are attended with hemi-anopsia, pro- 
vided the external geniculate body and the pulvinae are involved. 

Lesions of the corpora quadrigemina are attended with disturbances 
of vision (slight), a trxed dilated pupil, interference with the ocular 
motility, and ataxia (of the cerebellar type). 

Small lesions of the pons do not produce symptoms. In the ma- 
jority of cases, however, typical pons s^Tuptoms are presented. These 
corLsist in alternating paralysis, for example, left hemiplegia of the 
extremities, slight involvement of the face on that side, but complete 
paralysis of the right side of the face. A single nerve arising at the 
pons — for example, abducens, facial, hj-poglossal — may be para- 
lyzed. 

The principal symptom of a cerebellar lesion is so-called cerebellar 
ataxia (le marche d'ivresse), very similar to the gait of alcoholic 
intoxication. 

Involvement of the medulla oblongata is characterized by a complete 
or incomplete paraplegia or hemiplegia of the extremities, also anar- 
thria, dysphagia, aphonia, singultus, disturbances of respiration, and 
finally glycosuria. pol\Tiria and albuminuria, the last three indicating 
a lesion of the fourth ventricle. 

The treatment of recent injuries of the hrain, in cases in which 
localization of the lesion is impossible, is, of necessity, limited to the 
care of the injury of the .skull. It is a comforting thought that, as a 
rule, wounds of the brain do best when not tampered with. 

The fact that a drain injury is susceptible of localization does not 
of itself justify intervention. Indeed, as Kronlein^ very properly 
asks, ""WTiat can intervention accomplish? The repair of a brain 
injury is accomplished, as far as is possible, without our help ; and 
more than that Ls not to be hoped for." 

Only two conditions appeal for surgical aid, and these are question- 
able, the presence of a foreign body, such as bone splinters, sub- 



CONTUSIONS AND WOUNDS OF THE BRAIN 1525 

stances like portions of steel weapons, projectiles, etc., and the pre- 
vention of septic infection. 

As regards a forci^i body, determination of its presence may be 
fraught with great difficulties. This is not so difficult when the 
mechanism of the injury justifies a conclusion in this connection. To 
this class belong gunshot wounds with ports of entrance and exit; 
stab wounds in which the corpus delictij a knife blade, nail or hook 
remains embedded ; and open splintered fractures of the convexity of 
the skull, discoverable by the eye, the finger or the radiogram. Diffi- 
culties, often insurmountable, are presented when a conclusion in this 
connection must rest on the focal disturbances of brain functions. The 
appearance of these symptoms is of course entirely dependent upon 
the degree of irritation or paralysis that the foreign body produces 
(if any) or whether it is located in a portion of the brain the physi- 
ology of which is unknown. The immediate appearance of symptoms 
indicates injury by a foreign body. 

In this connection, the aid given us by the Rontgenogram is of 
inestimable value, especially with regard to the presence of projectiles. 
Despite the divergent opinions which at various times have been 
obtruded into the literature of the surgery of the brain, the writer 
feels justified in- subscribing to the conclusion of Chatelin and de 
Martel,^ that the ideal therapy in this class of cases con- 
sists IN REMOVAL OP THE FOREIGN BODY. The reasons for this are sum- 
marized by Kiittner'' as follows: The presence of the foreign body 
interferes with reprair and may entirely prevent it ; the foreign body 
is a constant source of concern, and is frequently responsible for 
serious functional, general disturbances or local processes which, after 
years of time, may destroy the host ; it may 'be responsible for jack- 
sonimi epilepsy, certain psychoses and late traumatic abscess and 
meningitis. Kiittner'' makes an exception with regard to very small 
projectiles which cause little trauma and, unless located in a readily 
accessible area, may be permitted to remain in situ. He adds that 
when the dangers of removal of the foreign body are greater than 
those obtaining in a policy of expectancy, the latter should be followed. 
7w cases of wounds of the cerebral cortex complicated by splintered 
fracture of the vault of the cranium, primary removal of the splinters, 
together with all foreign material, and thorough cleansing of the 
wound are indicated. Macerated portions of brain are best removed 
with gauze wipes, and bleeding arrested by means of iodoform gauze 
tamponade. The earlier this is done, the better the prognosis. 



1526 SURGERY OF THE HEAD 

In injuries of the brain not accessible through an open wound, in 
which the presence of splinters of bone is suspected, the question of 
operative relief is not so easily answered. This is determined by the 
surgeon's conception of the degree of the brain injury, based upon 
the character of bone injury he is confronted with. This includes 
splintering of the internal table in simple and restricted compound 
fractures, stab fractures, gunshot wounds with blind fractures, and 
small wounds of entrance. When injuries of this sort are located over 
the motor cortical zone, operative attack is indicated, especially when 
sjTnptoms of brain irritation are present. Exposure of the lesion is 
accomplished by trephining (p. 1564). Although pro.jectiles are 

NOT BY ANY MEANS FREE FROM BACTERIA, THE 0PERATI\T: TREATMENT OF 

gunshot wounds and their chemical disinfection is not advisable. 
However, trephining in this class of cases is indicated for the 
purpose of removing the foreign body, including splinters of 
BONE, and thus permitting unhampered repair of the lesion. From 
this standpoint, operative measures are justified, but onl}^ when re- 
moval of the offending agent does not magnify the already existing 
trauma to the brain. If this rule is followed, the number of operative 
cases will be small. Probing of the canal of a gunshot wound is never 
permissible. When the projectile is deeply located, its extraction must 
be desisted from unless the s>Tnptoms presented can be definitely 
ascribed to its presence. In determining the accessibility of projectiles 
along the lines stated, the Rontgenogram is of great assistance. 

As far as infection is concerned, the primary operative treatment of 
wounds of the brain is justified when the mechanism of the produc- 
tion of the injury presupposes the entrance of foreign substances. 
The latter are the conveyors of infection and must (if accessible) be 
removed. The technic of the care of these wounds consists in the ex- 
traction of bone splinters, careful cleansing of the wound area, re- 
moval of clots and macerated portions of brain tissue, incision of the 
dura — when retention of wound secretion seems likely — excision 
of contused soft parts, complete hemostasis, arrest of oozing (by pres- 
sure), and, finally, light tamponade of the wound with iodoform 
gauze. Antiseptic lavage and closure of the wound by suture are 

TO BE AVOIDED. 

The treatment of gunshot wounds of the brain in war is still the 
subject of discussion. Although routine operative measures of relief in 
all eases were practiced by a number of surgeons during the Boer and 
Russo-Japanese wars, the conclusion arrived at by a careful study of 



CONTUSIONS AND WOUNDS OP THE BRAIN 1527 

the observations recorded by a large number of surgeons serving during 
the world war may be expressed by the following, quoted from Chate- 
liu and de Martel :' "We cannot admit the principle that every foreign 
body ill the brain should be removed. . . . In any event, opera- 
tion, b}^ dividing fresh nerve fibers, adds to the damage already ex- 
isting and is likely to add to the patient's troubles. We are of the 
opinion that, in the case of a foreign body in the brain, no surgical 
interference is required unless this should be called for by some 
special symptom pointing to infection." In tangential gunshot 
wounds of the skull, in which the brain is injured, the operative meas- 
ures are aimed at removal of splinters of bone and at drainage. 

BIBLIOGRAPHY 

1. Kronlein. Korres. f. Schweizer Arzt., 1882, 1891, 1896; Beitr. z. 

klin. Chir., 1895, 1899, 1900. 

2. ZiEGLER. Lehr. d. Allg. Pathol., etc., 1898. 

3. TscHiSTOwiTSCH. Beitr. z. path. Anat., etc., 1898. 

4. Rahm. Diss. Zurich, 1896. 

5. v. MoNAKOW. Gehirnpath., Vienna, 1905. 

6. KuTTNER, in Handb. d. prakt. Chir. i, 1913, 

7. Chatelin and de Martel. Med. and Surg. Therap. iii, N. Y. and 

London, 1918. 



CHAPTER IV 

TEAUMATIC MENINGITIS 

When infection occurs in connection with injuries of the contents of 
the cranium, evidences of inflammation dominate the clinical picture. 
The etiological factor in this contingency, unfortunately very frequent, 
is the invasion of pathogenic organisms, which, according to Macewen,^ 
are chiefly streptococci and staphylococci, occasionally the colon group, 
and at times the proteus vulgaris. The development of a tuberculous 
meningitis in connection with trauma seems to have been shown 
(Kiittner^). As a rule, the bacterial excitants gain access to the 
menin'ges through a wound in the skull. Occasionally the infection is 
hematogenous in origin. However, even in these cases, local trauma 
would seem to determine the development of meningitis. Injuries' at 
the base of the skull are frequent ports of entrance. 

Traumatic meningitis appears in the form of leptomeningitis with 
the formation of a seropurulent, fibropurulent and purely purulent 
exudate which fills, to a greater or lesser extent, the meshes and lymph 
spaces of the pia and often obliterates the gyri and sulci of the brain. 
At times, it invades the brain substance itself, thus presenting the 
picture of eTicephalomeningitis. When this process occurs in connection 
with bloody extravasation (traumatic), ecchymotic areas alternate with 
the yellow color of the inflammatory zone. The pial inflammation is 
attended with a similar process involving the dura — traumatic pachy- 
meningitis purulenta externa and interna. 

Traumatic meningeal inflammation may be divided into early and 
late meningitis, depending upon whether the infection begins with the 
trauma or develops during the process of repair. The former may 
become manifest within a few hours, the latter may not make its bane- 
ful appearance until weeks or months after the injury has been 
inflicted. Late meningitis is especially likely to develop in connection 
with retained foreign bodies, necrosed portions of bone and con- 
fined necrotic soft parts, wound secretions and trombi, especially of 
the venous sinuses. So it not rarely happens that an insidious ne- 
crotic osteitis or a contused area of the cortex, after a variable period 
of time, suddenly erupts into purulent meningitis. 

1528 



TRAUMATIC MENINGITIS 1529 

The clinical picture of traumatic meningitis is rarely presented 
alone. In the early forms of the alllietiun, the symptoms usually co- 
exist with those provoked by the concomitant causation, such as con- 
cussion, compression, and contusion of the brain, and, in the late 
forms, the picture is very likely to be blurred by the simultaneous de- 
velopment of encephalitis and traumatic brain abscess. However, the 
course of suppurative meningitis is always acute and, while a restricted 
process may possibly end in recovery, the rule is that death ensues in 
a few days. 

For this reason, the presentation of a clearly defined clinical picture 
of traumatic meningitis is hardly possible. If, in connection with a 
head injury, the patient suddenly develops the symptoms of severe 
infection with violent headache, wild delirium, rapid pulse and great 
thirst, and presents a positive Kemig, and this is followed by hyper- 
esthesia of the skin, sinking of the abdomen, stiffness of the neck, 
convulsions, muscular rigidity, and, finally, stupor and coma, the in- 
ference is that he is afflicted with purulent meningitis. This sequence 
of events is soon succeeded by Cheyne-Stokes respiration and death. 
The diagnosis may be verified by examination- of the fluid obtained by 
lumtar pmwture (p. 1414), 

The treatment is really that of prophylaxis and this is encompassed 
in the aseptic care of wounds of the skull. The comparative rarity of 
the disease in civil life accentuates the blessings of asepsis. 

As the administration of urotropin (2-4 gr. pro die) is followed 
by its appearance in the cerebrospinal fluid in the form of free formal- 
dehyd, it has been employed as a prophylactic measure against infec- 
tion in cases of injuries of the brain (Crowe^). In cases of moderate 
virulence, it inhibits the bacterial flora (Denk and Leishner*). When 
the process is fully established, a fatal outcome is certain. In the 
circumscribed form of the disease, the part should be widely exposed 
with the view to establish drainage. For the purpose, large areas of 
bone have been removed with a successful outcome in several instances 
(Macewen,^ Schlesinger^ and others). 

BIBLIOGRAPHY 

1. Macewen". The Purulent Infectious Diseases of the Brain and Spinal 

Cord, London, 1898. 

2. KuTTNER, in Handb. d. prakt. Chir. i, Stuttgart, 1913, 

3. Crowe. Bull. Johns Hopkins Hosp., 1909, April, 

4. Dexk and Leishner. Internat. Cong., 1911. 

5. Schlesinger. Berlin klin. Woch., 1907, No. 47, 



CHAPTER V 

HEENIA OF THE BEAIN 

The escape of brain tissue from the cranial cavity occurs in con- 
nection with wounds involving the coverings of the brain, most fre- 
quently in compound fracture of the vault of the skull, although, as 
already stated, brain substance may ooze from a fracture of the base 
(nose, orbit, and ear). It is most frequently observed in connection 
with gunshot wounds. 





Fig. 748. — A, Hernia of the Brain in Connection with Compound Fracture 
OF THE Skull; B, Spontaijeous Eegression and Healing. 

The primary extrusion of brain substance of itself is not always of 
grave prognostic import, although the location from which it comes has 
a bearing upon the question of impairment of function. The outlook 
is very unfavorable when infection occurs under these circumstances. 

True hernia cerebri (prolapse) usually develops in the second week 
following the injury. The pia may cover a part of or the entire pro- 

1530 



HERNIA OF THE P.RAIN 1531 

trusion which may reach considerable dimensions (Fig. 748A). The 
extruded brain soon becomes livid or black from extravasated blood, 
while its surface softens and becomes gangrenous. If the develop- 
ment of encephalomeningitis is not rapidly fatal, the necrotic portions 
of brain tissue are cast off and the tumor shrinks. Usually, the 
shrunken protrusion is ultimately covered with (epidermis (Fig. 748B), 
leaving a pulsating area corresponding to the defect in the skull; 
this eventually may be covered with an osteoplastic flap (p. 1567). 

The etiology of cerebral hernia is directly ascribable to increased 
intracranial pressure. In cases of traumatism, this is the result of the 
accumulation of inflammatory exudate, including intracerebral abscess. 
In other instances, the protrusion is due to the increased pressure from 
inoperable tumors in which the decompressive craniectomy has been 
performed. This suggests that the latter be not blindly executed. 

Kiittner^ calls attention to the appearance (in connection with 
compound fractures) of the formation of an infectious hemort'hagie 
granuloma which bears some resemblance to hernia cerebri, but is 
really a fungus-like protrusion of contused brain tissue, provoked by 
the presence of foreign bodies and splinters of bone. In these cases, 
ablation of the mass is followed by healing. 

BIBLIOGRAPHY 

1. KtJTTXER, in Handb. d. prakt. Chir. i, Stuttgart, 1913. 



CHAPTER VI 
ABSCESS OP THE BRAIN 

Localized collections of pus in the brain are divided into : 

1. Acute traumatic cortical abscesses. 

2. Chronic traumatic deep seated abseessea. 

3. Otitic abscesses. 

4. Rhmogenous abscesses. 

5. Those occurring in connection with carious and ulcerative 
changes in the ear or other portions of the skull. 

6. Metastatic abscesses. 

To these may be added the suppurative processes occurring in con- 
nection with acute infectious diseases (epidemic cerebrospinal menin- 
gitis, tj-phoid fever, scarlatina, measles, influenza, etc.) and those 
attendant upon the invasion of ray and other fungi, tubercle bacilli, 
and the spirocheta pallida. 

Abscesses developing in the course of cerebrospinal meningitis and 
in actinomycosis are rare (see literature of Oppenheim^ and v. Berg- 
mann^). Circumscribed brain tuberculosis and gumma present more 
the picture of brain tumor. The former occurs in connection with 
caries of the skull of otic origin. 

Acute Traumatic Cortical Abscess. — Acute traumatic cortical abscess 
of the brain occurs most frequently in connection with compound frac- 
ture of the skull. In this event, it is likely to be a part of a general 
leptomeningitis which dbminates the clinical picture. "When, however, 
the pyogenic process is limited to a confined cortical area, the symp- 
toms are those of a localized cerebral lesion (muscle spasm, contrac- 
tures, paral3\sis, etc.). The development of evidences of inflammation 
at a considerable period of time (days) after the injury suggests 
abscess rather than meningitis. The treatmeni consists in enlarging 
the opening in the skull and evacuation of the pus. Doubt as to the 
diagnosis does not justify a policy of procrastination, as in lepto- 
meningitis no harm can come from wide exposure of the region of an 
infected compound fracture of the skull (v. Bergmann,^ Chatelin and 

de MarteP). 

1532 



ABSCESS OF THE BRAIN 1533 

Chronic Traumtic Abscess. — Chronic traumatic abscess of the brain 
is iLsually located in tlie deeper tissues of the medullary substance. It 
is due to three causes. It may develop sequentially to an acute abscess, 
i. e., the greater part of the abscess may discharge externally, the 
outer tissues heal and the residual infection slowly develop into a 
chronic abscess. Tliis is especially likely to happen in fractures of the 
base of the skull. A second cause of chronic abscess is the retention of 
an cnihedded foreign hody, especially a projectile. The third eti- 
ological factor in'thromhosis, which develops in connection with chronic 
otitis media and osteomyelitis and invades the vems and the skull and 
sinuses, thus gaining access to the veins of the cerebrum. This occurs 
in processes that are not due to trauma. To those stated, must be 
added the rare instances in which an abscess develops at the site of a 
contusion, the outcome of contre coup. 

All chronic abscesses of the brain are characterized by a so-called 
pyogenic mcmhrane. Cassirer* has shown that this membrane does not 
act as a demarcation of the process and that the contiguous portions of 
the brain are often invaded through it. This acounts for the periods 
of exacerbation of symptoms common to brain abscess. In many in- 
stances the restricting deposit of connective tissue is very thin, so 
that the abscess either ruptures into the ventricle or upon the surface 
of the brain and ends the problem with the picture of diffuse purulent 
meningitis. An acute abscess terminates in from three to five weeks. 
After this it takes/ on the characteristic of the chronic form of the 
lesion, the persistence of which is very indefinite. Much depends upon 
its location. 

The diagnosis of chronic brain abscess rests on its peculiar course. 
The brain symptoms immediately associated w^ith the injury, the 
so-called primary symptoms, are followed by a period of latency 
which is more or less clearly defined, and this is followed later 
by secondary and terminal symptoms. In traumatic cases this 
is easily understood. The primary symptoms are the outcome of the 
lesion produced by the original injury, i. e., concussion, contusion, 
hemorrhage, etc. When these processes become quiescent, the symp- 
toms that the host develops are dependent upon the location of the 
abscess. We know now that the conducting elements of the brain 
may be forced apart by purulent processes of considerable magnitude 
without destruction of their conductivity, and thus no symptoms are 
developed. This enlargement occurs intermittently until rupture 
into the ventricle or on the surface of the brain occurs. The degree 



1534 SURGERY OF THE HEAD 

of the primary injury is not in any sense indicative in this connection, 
being" slight iu one instance and very severe in another. The period of 
latency is widely variable. At times, this is entirely free from symp- 
toms, at others, attended with irritability, headache, vertigo, mental 
depression, varying' with quarrelsomeness and, not rarely, intermit- 
tent somnolence and subconsciousness. In some instances, melan- 
cholia and a tendency to suicide develop. Cerebral edema is the most 
common cause of death, next, rupture of the abscess into a ventricle. 

The symptams following the period of latency are indefinite and 
often limited to neuralgic pain and headache. Radiation of the latter 
from the site of the injury and the fact that it is increased in severity 
by certain movements of the head and body are of diagnostic value. 
The neuralgic pain is practically limited to the distribution of the 
fifth nerve. To these are added the symptoms of increasing general 
hroAn pressure, such as vertigo, vomiting, slowing of the pulse rate, 
and choked disk. The last is more likely to occur in connection with 
brain tumor. Brain abscess may be attended with fever. However, un- 
fortunately, this symptom of abscess, ordinaril}^ so valuable, is often 
absent and, as a matter of fact, when present is more indicative of 
mening-itis and encephalitis (Oppenheim*). In connection with abscess, 
fever is not obtrusively present until the process has ruptured on the 
surface of the brain and has involved its coverings. 

Clearly defined focal symptoms are of definite value in the diagnosis 
of brain abscess, especially when they occur sequentially to headache 
and fever. Very often the lesion is uncovered by the sudden appear- 
ance of convulsions. They begin with a crj^ and a convulsive tremor 
involving the entire body and are the precursors of a series of brain 
symptoms. Or, a transitory epileptiform seizure is soon followed by 
a second and third attack and these are ultimately succeeded by evi- 
dence of brain lesi'on. The focal symptoms are no different from those 
occurring from other causes. 

"When an evening rise of temperature is followed by headache and 
convulsive attacks, and, later, paralysis of one side of the body develops, 
the presence of an abscess of the brain is very probable" (Kiittner"). 
At this time the behavior of the wound may indicate the presence of 
abscess, i. e., the granulations are distended and the edges of the wound 
become edematous, the latter condition frequently extending over the 
entire scalp. Often fragments of bone are extruded from the opening 
in the skull. The presence of streaks of pus between the granulo- 
matous masses is indicative of abscess and too often escapes notice. 



ABSCESS OF THE BRAIN 1535 

The treatment of abscess of the brain aims at the early evacuation of 
pus, employing the technic of trephining (p. 1564), if necessary. There 
is no more imperative indication for the latter than that of affording 
egress for pus (Kiittner-')- This is justified when there is suspicion 
of the presence of pus. It is desirable that the end be attained by 
enlargement of the original solution of continuity of the skull. In all 
cases the opening must be an ample one. The return of pulsation in 
the affected area indicates that the purpose has been accomplished. 
During the operation the presence of pus may be announced b}' dis- 
coloration of the dura or by its dull appearance. When opening the 
dura does not disclose the presence of pus, the brain tissue may be 
explored with the hollow needle or a thin flat scalpel. Many years 
ago, Dupuytren'' employed the latter measure with success. Employ- 
ment of the Neisser-Pollack'^ brain p-uncture through the intact skull 
is permissible, but only if the operator is prepared to open the cranium 
immediately in the event of the discovery of pus (Oppenheim*). The 
results following the operation, are very favorable. Of 77 cases 
collected by Oppenheim and Cassirer,* 56 recovered (see also 
Lewandowski^). 

Otitic Brain Abscess. — Otitic brain abscess is of traumatic and otitic 
origin. Its frequency is made the subject of a comprehensive statis- 
tical review hj Kiittner.^ 

Abscesses originating from the auditory apparatus develop as the 
result of the extension of chronic inflammatory processes from the 
ear. Such abscesses occur most frequently in connection with choles- 
teatomata (p. 1242). These neoplasms destroy the bony structures and 
provide an avenue of entrance for the infection. As a rule, the process 
extends directly from the bone, rarely from the mucosa. The chronic 
suppurative ear diseases concerned in the production of abscess of the 
brain are (1) those attendant upon cholesteatoma; (2) the putre- 
factive bone infections; (3) those presenting an intermittent picture 
with acute exacerbations ; (4) those developing from polypoid growths 
in the tjTnpanic cavity and in the external canal; (5) those originating 
from perforation of the drum. 

It is important to establish (if possible) the presence of the primary 
suppuration in the petrous bone, as the seat of the abscess corresponds 
to the location of the suppurative process in the ear. Suppuration in 
the t^Tnpanic cavity which invades the mastoid antrum extends to the 
mastoid cells, whence it reaches the outer surface, or an extradural 
sbs^ps? in the lateral sinus between the blood vessel and the bone is 



1536 SURGERY OF THE HEAD 

formed. This suppuration may produce thrombosis of the vein or it 
may extend beneath the tentorium and produce an abscess in the 
cerebellum. According to Jansen," cerebellar abscess may also follow, 
suppuration in the labyrinth. Suppuration in the lateral sinus, either 
with or without sinus thrombosis, leads to abscess in the lateral por- 
tion of the cerebellum, while a similar process in the labyrinth leads 
to abscess in the median lobe. In necrosis of the attic of the tym- 
panum, suppuration may extend along the auditory nerve causing an 
accumulation of pus above the tegmen (extradural) or it may invade 
the ceredrum. The third temporal convolution and the gyrus fusi- 
f ormis are most often involved. 

The diagnosis of otitic brain abscess, like the traumatic, rests mostly 
on a consideration of the etiological factors. The other symptoms may 
be arranged in three groups, 1. the symptoms indicative of a 

SUPPURATIVE PROCESS; (2) THE SIGNS OF INCREASED INTRACRANIAL 
PRESSURE; (3) THE EVIDENCES OF FOCAL IRRITATION, OR OF LOSS OP 

BRAIN FUNCTION. The first consist in the sjonptoms of fever. However, 
this is of so low a grade that Macewen" considers that a verj^ high 
temperature argues against otitic abscess. In the second group belong 
vomiting and headache. The latter is worse at night and increased by 
percussion over the site of the abscess (v. Bergmann^). Vomiting 
occurs independently of ingestion and is exacerbated when the patient 
moves. To these sj-mptoms are added lassitude, inattention, slowness 
of speech and a tendency toward somnolence. Slowing of the pulse 
rate is characteristic and is more so when headache is at its worst. 
Choked disk is an important sign. In the third group the focal symp- 
toms would be most suggestive, were it not for the fact that they are 
often absent, and, when present, may be due to epidural suppuration 
or sinus throbosis. The character of the focal s\Tnptoms is dependent 
upon the seat of the lesion (see cerebral localization, p. 1520). 

Otitic cerebellar abscess is not readily diagnosticated. A clearly de- 
fined clinical picture is the exception. Much of the cerebellum may be 
involved before sufficient pressure is made on the worm to produce 
uncertain gait, vertigo, nystagmus and rigidity of the neck. In the 
beginning, disease of the labj'rinth is usually suspected. By exposing 
the mastoid process and following the path of infection the location 
of the abscess may be discovered. 

To recapitulate: The question of differentiation arises between 
otitic TEMPOROSPHENOIDAL or CEREBELLAR ABSCESS on the One hand, and 

PURULENT MENINGITIS, INFECTIOUS SINUS THROMBOSIS, AN EXTRADURAL 



ABSCESS OF THE BRAIN 1537 

SUPPURATION, or a SIMPLE EXTENSION OF OTITIS MEDIA SUPPURATIVA TO 

TUE PNEUMATIC ACCESSORY SINUSES, on tlic otlicF. Braiii puncture 
clears up the diagnosis but, as already stated, this may be employed 
only when the surgeon is prepared for immediate operative evacuation 
of the pus in the event of positive findings. 

The treatment of otitic abscess consists in its evacuation. 

T cmparosplienoidal abscess is approached in two ways. One is the 
method of Stacke,^' in which the abscess is approached through the mas- 
toid antrum. The other, that of v. Bergmann,^ is, in all essential 
regards, similar to the decompressive operation of Cushing (p. 1497). 
The latter method has the advantage of permitting the extension of 
the skull section backward to the cerebellum and forward to any de- 
sired extent. When the abscess is uncovered, it is incised, and the 
opening is enlarged with forceps. Tube drainage is universally em- 
ployed, bcmg maintained until no more pus is discharged. 

Rhinogenous Brain Abscesses. — Rliinogenous brain abscesses occur 
in connection with suppurative processes in the upper nasal pas- 
sages AND THE ACCESSORY CAVITIES, AND IN THE FRONTAL, SPHENOIDAL 
AND MAXILLARY SINUSES. 

The same endocranial infection occurs in these instances as happens 
in connection with the ear and its accessory sinuses, i. e., abscess in 
the frontal lobe, extradural suppuration, meningitis, and thrombosis 
of the cavernous sinus. The paths by which the infection enters the 
cranium have been studied by Herzfeld.^^ As a rule, the bony wall of 
the affected sinus is perforated, but in some instances the infection 
travels along the olfactory nerve. 

It is a well recognized fact that a considerable portion of the frontal 
lobe of the brain may harbor an abscess without the occurrence of dis- 
tinctive symptoms and that these do not appear until the process ex- 
tends to the motor zone (especially the speech center). The sequence 
of symptoms may suggest the presence of an abscess, especially if the 
clinical picture of gradually increasing brain pressure is attended 
with a low grade of fever, and then focal symptoms suddenlj- occur. 

The treatment of abscess of the frontal lobes consists in opening the 
frontal sinus (if necessary) and invasion of the cranial cavitj' through 
the posterior wall of the latter. A remarkable series of illustrations 
showing the widely varying relationship the frontal sinuses bear to 
the brain is produced in connection with the work of Onodi,^^ who also 
furnishes a complete bibliography pertaining to the subject. 

Abscesses Beneath Ulcerative Processes. — Abscesses beneath otitic, 



1538 SURGERY OF THE HEAD 

osteomyeliiic, carious and ulcerative processes are comparatively rare. 
On the other hand, any infectious process in the cranial bones may be 
attended with intracranial suppuration. To this class of cases belong 
the so-called late traumatic abscesses. These are briefly but sufficiently 
discussed by Chatelin and de Martel.^ Cerebral abscesses occurring in 
connection with tuberculous and luetic bone lesions are also uncommon, 
3'et they do occur (Krause"). Chatelin and de MarteP saw a num- 
ber of these cases during the world war, which were sequential to 
projectile wounds of the brain. The diagnosis is based on the focal and 
general symptoms already taken up, and these, de IMartel states, are 
not as illusive as is generally believed, provided the case is thoroughly 
studied and complete blood and cerebrospinal fluid examinations are 
available. 

Metastatic Abscesses. — As metastatic ahscess of the hrain has been 
surgically attacked in the past few years, it presents peculiar interest. 
It occurs in connection with infectious processes located in more or 
less remote sectors of the bod.v, especiallj- the intrathoracic organs. 
Unfortunately, a single metastatic abscess of the brain is rare, several 
suppurative foci usually being present. Of 22 cases of cerebral abscess 
collected by Martins,^" D were solitary. The condition is most often 
associated with putrid and purulent pulmonitis. Claj^tor,^*^ in 58 cases 
of brain abscess, found bronchiectasis in 29 ; purulent bronchitis in 10 ; 
empj-ema in 7, which, except one, were the result of gunshot wounds ; 
the rest were due to tuberculosis. 

The causative embolus seems to show a predilection for the zone 
of the Sylvian artery, which Martius^^ explains on a somewhat involved 
mathematical basis. When the embolus reaches the end of its journey 
ill the motor zone, the clinical picture is that of an acute cortical lesion 
and this is succeeded by a train of sj'mptoms which do not vary from 
those already taken up in connection with traumatic abscess. 



BIBLIOGRAPHY 

1. Oppenheim. Spec. Path, and Therap. Nothnagel. 

2. V. Bergmann. Die Chir. Behand. v. Hiinabscess (3d ed.), 1899. 

3. Chatelin and de Martel. Med. and Surg. Therap. ill, N. Y. and 

London, 1918. 

4. Oppexheim and Cassirer. Der Hirnahscess, Vienna, 1909. 

5. KiJTTNER, in Handb. d. prakt. Chir. i, Stuttgart, 1913. 

6. DupuYTREN. Quoted by No. 5. 

7. Neisser-Pollack. Mitteil. a. d. Grenzgeb. f. Chir., 1909. 

8. Lewaxdowski. Handb. d. Neurol., 1912, iii. 



ABSCESS OF THE BRAIN 1539 

9. Jansen. Verb. d. Deutseh. otolog. Gesell., 1895. 

10. Macewen. Inf. Suijpurations of the Brain, etc., London, 1898. 

11. IStacke. Die op. Freilegung des Mittelohrriiume, 1897. 

12. Hekzeeld. Berlin, klin. Wocli., 1900. 

13. OxODi. Zeitst'hr. f. Lar}^l. Rhin., etc., Wiirzburg, 1911. 

14. Krause. Surg, of the Brain, etc., i, N. Y., 1909. 

15. Martius. Deutsch. militiiriirzt. Zeitschr. xx, 1890. 

16. Claytou. Quoted by No. 5. 



CHAPTER VII 
THEOMBOSIS OF THE IXTEACEAXIAL SINUSES 

Although two kinds of thrombosis are recognized — primary maras- 
mic, and secondary' infectious — the latter only possesses surgical 
interest and will be discussed here. 

Infectious Sinus Thrombosis. — Infectious sinus thrombosis is a not 
unusual and a much dreaded complication of the various purulent pro- 
cesses in the soft parts and the bony structures of the head. It plays 
an important role in the problem presented b}' the latter, especially 
with regard to measures of relief. 

Sinus thrombosis originates from a number of lesions, such as in- 
fection of soft parts and wounds of the bones of the face and skull, 
phlegmons in these regions, en;'sipelas, general infectious processes of 
the mouth, nose and its accessory sinuses, and last, but surely not least, 
the orbital cavity. 

Most feared of all perhaps is the furuncle of the upper lip, the 
occasional origin of an infection which produces a purulent thrombo- 
phlebitis in the angular vein whence it travels by way of the ophthal- 
mic into the cavernous sinus. In not a few instances an apparently 
innocent dental periostitis of the upper jaw or an inflammatory pro- 
cess in the tonsil is the point of origin of a menacing sinus phlebitis. 
The process also originates from contiguous brain abscesses and sup- 
purative meningitis. However, the reverse is more often true, and 
both conditions are the result of the same cause. By far the most 
FREQUENT CAUSE (in two thirds of the cases) of sinus phlebitis is a 
SUPPURATIVE PROCESS IN THE EAR (Korncr^). Although young per- 
sons between the ages of ten and twenty years are most fre- 
quently attacked (Hessler^), no age is exempt. The mastoid portion 
of the petrous bone is the avenue by which the infection travels from 
the middle ear to the lateral sinus. The assumption that sinus phlebi- 
tis occurs most often as the outcome of chr&yiic otitis media has been 
shown to be an error ; the condition is most frequently associated with 
acute processes in the middle ear. The infection is produced by 

1540 



THROMBOSIS OF INTRACRANIAL SINUSES 1541 

streptococci, stapliylocooci, pneumococci and occa.sionally by the 
bacillus proteus vulgaris. Besides the sinus infections which extend 
by the bony tissues, another form, that of osteophlchiiis, is not un- 
common. In this form the infection travels by way of the mastoid 
venae emissariae. This is especially likely to happen in cases of severe 
infection of the middle ear associated with so-called influenza. 

As already stated, the sigmoid portion of the transverse sinus is 
most often affected. However, primary involvement of the petrous 
sinus and the bulb of the jugular vein is not excluded. In sinus throm- 
bophlebitis other than the otogenous, that of the cavernous sinus is the 
most frequent. The pathogenesis of the process is taken up in the 
general part of this work (p. 999). 

The clinical picture of infectious sinus phlebitis is that of a septic 
general infection with certain local symptoms. 

The local symptoms are provoked by the disturbances of the circu- 
lation. They are, however, likely to be masked l)y the inflammation 
of the surrounding tissues. The cerebrospinal fluid is increased in 
amount and, as this becomes greater, the symptoms of intracranial pres- 
sure, preceded by evidence of cerebral irritation, are more or less 
rapidly developed. Headache is an early and constant symptom ; to 
this is soon added nausea, vomiting end vertigo, i. e., so-called brain 
symptoms. Differentiation from brain abscess is based on the acute- 
ness of the symptoms, including those indicative of a systemic infec- 
tion, while clearly focal ibrain symptoms are lacking. Optic neuritis 
is usually absent in sinus phlebitis, while in abscess it is often present. 

Objective local symptoms, unfortunately not always present, are 
very helpful. In thrombosis of the transverse sinus, the presence of 
a circumscribed area of edema at the mastoid process is pathognomonic 
of thrombophlebitis of the emissaries (Greisinger^). This must not be 
mistaken for the inflammatory edema 'often found distributed over a 
suppurating mastoid process. At times deep seated local tenderness 
may be elicited at the former point and the muscles of the neck are 
stiff and painful. However, Korner^ considers that these symptoms 
are also present in cases of perisinuous suppuration. Voss* claims 
that, when lateral sinus thrombosis is present, the "venous hum" in 
the jugularis is absent. 

"When the thrombus extends into the jugularis, the vessel may be 
palpated as a hard, painful cord beneath the anterior edge of the 
sternomostoid mtiscle, but a negative finding in this regard is in no 
sense decisive. 



1542 SURGERY OF THE HEAD 

Of much more diagnostic significance are certain evidences of pres- 
sure of the thrombosed sinus upon the nerves which pass out of the 
jugular foramen with the vein, i. e., the vagus, the spinal accessory 
and the glossopharjnigeal. Some of these may be the result of exten- 
sion of the inflammation to the nerves. The nerve symptoms arising 
from vagus involvement are hoarseness, dyspnea, and slowing of the 
pulse. These may cause death. Those of the accessories consist in 
spasm of the sternomastoid and the trapezius, while impairment of 
the glossopharyngeal is e\^nced by inability to swallow and paralysis 
of the palate. In rare instances, the hypoglossal is involved in the 
condyloid foramen. Laurens^ speaks of tenderness over the occiput 
as of diagnostic value and states that percussion over this zone, even 
in partially comatose patients, is responded to by what he calls ''cri 
de la pySniie." 

Korner^ states that thrombophlebitis of the petrosal sinus does not 
present loeal symptoms and rarely causes pyemia. 

Infectious thrombosis of the longitudinal sinus is infrequent. It 
may develop in connection with otogenous menmgitis and by exten- 
sion from the confluent sinus. It does, however, occur in association 
with infected compound fractures of the skull, erysipelas or phleg- 
monous inflammations of the scalp. Infection of this sinus is often 
attended with dilatation of the veins of the hairy scalp (Lermoyez"). 
According to Gradenigo,'^ an edematous, turgescent area may not 
infrequently be discovered over the anterior central corners of the 
parietal bones. He regards this of diagnostic value. Occasionally 
the eyelids are edematous. 

The dominant local symptoms of phlebothrombosis of the cavernous 
sinus consist in a tense edema of the eyelids with chemosis, together 
with exophthalmus which is caused by retrobulbar edema. Thus is 
presented a characteristic clinical picture. Pressure on the nerves in 
this region is evidenced by neuralgic pain in the first branch of the 
fifth nerve and in paralysis of the muscles supplied by the motor 
nerves of the eyeball (Hinsberg,^ Kramm,^ Marum,^° Sagebiel,^^ 
Travernier,^- Thomson^^). 

While one or more, and perhaps all, of the local symptoms enume- 
rated may be absent, and, in many instances, are only recognized upon 
careful examination, the general clinical picture of sinus thrombosis is 
unmistakably that of general septic infection. This is extensively 
taken up in another portion of this work (Part II). 

The diagnosis of sinus phlebitis rests on the local and the general 



THROMBOSIS OF INTRACRANIAL SINUSES 1543 

symptoms taken into account in connection with the history of a 
causative infection in the ear, nose, orbit, skull and scalp. After a 
voluminous presentation, Korner' regards the recognition of a hard 
.tender cord in the neck and evidence of pressure on the seventh and 
ninth nerves as most indicative of thrombosis of the bulb. Of the 
general symptoms, the clinical picture of a grave general infection is 
perhaps most determining, especially when this is verified by the blood 
findings (Lcutert^^). The observations of Oppenheimer^^' are particu- 
larly illuminating in this connection. 

The prognosis of infectious sinus thrombosis may be summed up as 
fatal in all instances not relieved by operative measures, and of the 
latter two out of three recover (Korner^). 

The operative treatment of sinus thrombosis owes its inception to 
ZaufaP" (1884), its dissemination to Lane,^' whose daring made the 
recording of a series of successes possible. The technic of the pro- 
cedure (after primary exposure of the antrum, p. 1655) consists in 
exposure of the infected sinus. If this is greenish or j-ellow in color, 
the diagnosis is clear. The sinus is widely opened and the infected 
thrombus is removed ; bleeding is readily controlled by tamponade. 
Unnecessary trauma must be avoided. The object of the operation is 
the establishment of drainage. When the sinus does not present vis- 
ible evidence of infection, it may be aspirated. If fluid blood is not 
obtained, thrombosis m present. In cases of extensive involvement 
the sinus may be exposed backward to the confluent sinus. Tlie neces- 
sity for LIGATURE OF THE INTERNAL JUGULAR VEIN is not established. 
The chief objection to the measure lies in the unfortunate fact that it 

DOES NOT OBVIATE THE ENTRANCE OF SEPTIC EMBOLI INTO THE GENERAL 

CIRCULATION, which is easy to understand from an anatomical stand- 
point. In this connection, the review of Haj-mann^^ is of interest. 
As far as the operative relief of thrombosis of the cavernous sinus is 

concerned, this has been attempted by Voss,* who employed a technic 
similar to that used for exposure of the ganglion of Gasser, and by 

Bircher^^ and Korner,^ without, however, an encouraging outcome in 
either instance. 

BIBLIOGRAPHY 

1. KoRNER. Die inf-eitrig. Erkrank. des Gehims, etc. (3d ed.), 1908. 

2. Hessler. Die otos:. Pyamia, 1896. 

3. Greisinger. Quoted bv No. 1. 

4. Voss. Zeitsohr. f. Ohrenheilk., 1907, iii. 

5. Laurens. Quoted by No. 1. 



1544 SURGERY OF THE HEAD 

6. Lermoyez. Quoted by No. 1. 

7. Gradenigo. Quoted by No. 1. 

8. HiNSBERG. Allg. med. Zentrblr. Zeitr., 1907, No. 14. 

9. Kramm. Zeitschr. f. Ohrenheilk, 1907, liv. 

10. Marum. Arch. f. Ohrenheilk., 1911, Ixxxv. 

11. Sagebiel. Zeitschr. f. Ohrenheilk;, 1909, Iviii. 

12. Tavernier. Lyon chir., 1909, ii. 

13. Thomsok. Zeitschr. f. Laryng. Rhinolog., etc., i. 

14. Leutert. Arch. f. Ohrenheilk., xli-xlvii-lxxiv. 

15. Oppenheimer. Zeitschr. f. Ohrenlieilk, liii, Ixiii.. 

16. Zaufal. Prager med. Woch., 1891. 

17. Lane. Quoted by No. 1. 

18. Haymann. Arch. f. Ohrenheilk. Ixxxiii, 1910. 

19. Bircher. Zentrblr. f. Chir., 1893, No. 22 



CHAPTER VIII 

EPILEPSY AND ITS SUEGICAL TREATMENT 

For the purpose of the surgeon it is fitting that the distinction 
between genuine and organic epilepsy be maintained. 

It would seem that the experimental work of recent j-ears has estab- 
lished the fact that a large number of cases of epilepsy are due to 
FOCAL lesions OF THE CEREBRAL CORTEX. Biuswaugcr^ has shown that 
fewer than one half of the cases of epilepsy in childhood are of the 
genuine variety, and A^ogt- insists that no case should be condemned 
to the hopeless class of genuine, or so-called idiopathic, epilepsy until 
a most thorough examination has been repeatedly made. As observa- 
tions in this connection multiply, the line of demarcation between the 
two groups of cases becomes less and less defined. This is especially 
notable when it is considered that jacksonian epilepsy often merges 
into the general form and the latter is frequently attended with the 
characteristics of the former. Both groups are also closely related in 
an etiological sense. With regard to congenital epilepsy, it is not 
improbable that in a certain number of cases external influences are 
necessary before the disease is actually developed in a person who is 
congenitally predisposed in this direction. The parts that congenital 
malformation and lues play in this are not yet clear. 

This varying susceptibility is the reason why we are not in a position 
to standardize the exciting cause of epilepsy in a quantitative sense. 
It is impossible to say w^hether a given injury of the skull or brain 
will be followed by epilepsy or not. On the other hand, it appears to 
be certain that aseptic opening of the skull is very rarely followed by 
epilepsy. Also there is no doubt that the disease is most frequently a 
sequel of injuries of the motor cortical zone. 

It is a disturbing consideration that local lesions are attended with 
gradual changes in the entire brain. While local cortical lesions 
dominate the picture at first, the general disturbances soon force these 
into the background. This occurs most rapidly in the brains of 
children. 

1545 



1546 SURGERY OF THE HEAD 

To the surgeon, the most important causes of epilepsy are those 
changes coincident with traumatism and with inflammatory lesions of 
the cerebral cortex. To these must be added tumors, which are often 
heralded by epileptic attacks that not rarely accompany their entire 
course, presenting the picture of general epilepsy. This is especially 
true of tumors located in the temporal lobe and involving the con- 
tiguous hippocampus major — which is supposed to have some connec- 
tion with epilepsy. The association of hydrocephalus and epilepsy 
has been shown by Yogt.^ 

Epilepsy as a sequel to head injuries may be arranged in three cate- 
gories. To the first •belongs the group of cases following injury of 
peripheral nerves in the coverings of the scalp — usually a scar ; to 
the second, those due to trauma to the bones of the skull or to the dura 
(for instance, hyperostoses of the intact or fractured skull or adhesions 
between the cranium and dura) ; to the third, injuries to the brain 
itself. The proportion of head injuries that are followed by epilepsy 
has been studied by a number of writers. Their fijidings and the 
experimental work of Westphal, Hitzig and Fritsch are reviewed by 
Kiittner.^ 

While there would seem to he no douht that head injuries are capable of 
producing changes in the hrain which are followed by epilepsy, it is also true 
that trauma of other parts of the body may be the exciting cause of the 
affliction in persons possessing a tendency toward epilepsy. This condition 
is designated as reflex epilepsy. 

In reflex epilepsy the causative lesion often involves the trunk of a 
large nerve, especially the sciatic, or the nerve is attached to the peri- 
osteum, Or is the seat of a foreign body. Nerves thus affected are 
exceedingly tender and an attack of epilepsy may be provoked by 
pressure upon the lesion. In many instances, the so-called aura 
emanates from the area of the involved nerve and it not rarely happens 
that complete development of an impending attack may be obviated 
by firmly encircling the central portion of the affected part. On this 
basis, nerves have been excised and limbs amputated with a not incon- 
siderable number of successes. Seeligmiiller'* has collected a number 
of cases of this kind. Reflex epileptic seizures have been relieved by 
the removal of foreign bodies from the upper air passages, and Frey 
and Fuchs'^ report cases of epilepsy apparently relieved by the treat- 
ment of chronic inflammatory conditions in the pharynx and larynx. 
The cessation of epileptic attacks following circumcision has been 
observed by most surgeons. However, the exact establishment of a 



EPILEPSY AND ITS SURGICAL TREATMENT 1547 

causative relationship is not in all instances possible. It is probable 
that the local cause must be removed before permanent changes have 
taken place in the brain, i. e., before the epileptic state is fully devel- 
oped. When the latter is present, attacks are precipitated by minor 
injuries (Jolly*^). Given an originally healthy bram, a peripheral 
injury will not produce epilepsy for many years, but when the disease 
is once established, an attack is induced by very slight irritation 
(Unverricht'). According to v. Bergmann,^ scars 'located in the scalp 
are miore likely to be followed by epilepsy than are those situated 
elsewhere. 

Compound fractures of the skull, especially the depressed variety, 
are frequently followed by epilepsy, although this also occurs as a sequel 
to fracture with loss of substance. In both instances, the convulsions 
are ascribable to changes in the tissues of the hrain. 

The theory of so-called cortical epilepsy is based on the fact that 
irritation of the cortex of the brain is attended with spasm on the 
opposite side of the body. This was demonstrated by Hughlings Jack- 
son'' (1861) mid its bearing on the study of epilepsy was brought out 
by Charcot,^" who coined the term jacksonian epilepsy. 

A large number of operative measures directed toward the relief of 
jacksonian epilepsy have been employed with varying success. These 
cannot of course be reviewed here. In standardizing the value of a 
procedure it must be remenlbered that during a certain period of time 
following any operation, epileptics -are likely to be free from attacks. 
At least three years n>ust elapse, free from attacks, before a case may 
be regarded as permanently relieved. In other cases, improvement may 
be claimed, if -the attacks are less frequent and less severe. 

The aim of the present day operative treatment is the removal of 
injured bone, together with the damaged cortex beneath it. The pos- 
sibilities in this connection were indicated by the case of v. Bergmann^ 
(1887), who extirpated the hand center in a case of traumatic epilepsy. 
Since then the method has become en vogue, principally as the outcome 
of the labors of Krause.^^ 

However, even these efforts are attended with many failures. Re- 
cently the results have been improved by a more exact ide^itification of 
the hrain area giving rise to the primary spasm. This is accomplished 
by means of a mild f aradic current. After preliminary double ligature 
of the vessels leading to the identified part, the cortex is excised to a 
depth of 5 mm., (Fig. 749). The immediate effect of this procedure is 
more or less transient paralysis of the part supplied by the excised 



1548 



SURGERY OF THE HEAD 




cortex. This is ultimately overcome, provided there is no infection of 
the vs^ound (Friedrich^-). The causative relationship between com- 
paratively slight head ijijuries and epilepsy, especially in children, 
has been shown by Fried- 
rich,^^ whose observations 
have been verified and data 
amplified by Weil.^^ 

In traumatic jacksonian 
epilepsy the operation must 
be performed early. How- 
ever, it is to be remembered 

that THE DISEASE IS NOT DUE 
TO THE INJURY BUT TO ITS 

CICATRIZATION and that 
trauma added to the pri- 
mary lesion is, therefore, 
objectionable. In cases of 
epilepsy due to a defect in 
the skull, closure by means 
of an osteoplastic flap is often followed by relief. 

Relief in cases of jacksonian epilepsy by operative measures is pos- 
sible. They are of no avail, however, in genuine epilepsy. The 
assumption of Kocher,^* that increased intracranial pressure is respon- 
sible for the changes the brain undergoes in epilepsy, is supported by 
the fact that the manometer shows the former condition to be present 
during an attack. On this basis, exposure of the brain is made, in all 
instances, by means of a large osteoplastic flap (Fig. 752). At this 
writing, most surgeons (after the cortical extirpation) excise the dura 
and close the defect by a free fascia and fat transplant (from the 
patient's thigh), upon which the osteoplastic flap rests. Recent clin- 
ical observations, including those of the writer, justify continuance of 
the method. 



4^ 



Fig. 749. — Excision of Area of Primary 
Spasm for Belief of Jacksonian 
Epilepsy. 



BIBLIOGRAPHY 

1. BiNSWANGER, in Eulenberg's Realenoyl. d. Med. (2d ed.). 

2. VoGT. Die Epilepsie imm Kindesalter, 1910. 

3. KiJTTNER, in Handb. d. prakt. Chir. i, 1913. 

4. Seeligmuller. Deutsoh. med. Woch., 1894, with lit. 

5. Frey mid FucHS. Arb. Obersteiners, xiii. 

6. Jolly. Charite Ann., 1896. 

7. Un\'erricht. Samml. klin. Vortr,, 1897. 



EPILEPSY AND ITS SURGICAL TREATMENT 1549 

8. V. Bergmann. Same as No. 3. 

9. JACKfSON. Med. Times and Gaz., 1861 and 18G3. 

10. Charcot. Kev. mensuelle, 1877. 

11. Krau.se. 8ury. oi" the Brain, etc., N. Y., 1909. 

12. Frikdricii. Arch. i'. kliu. Chir., Ixxvii. 

13. Weil. Beitr. z. klin. Chir., 1910, Ixx. 

14. KocuEK. Deutsch. Zeitschr. f. Chir., xxxvi. 



CHAPTER IX 

MENTAL DISEASES FOLLOWING CEANIAL INJURIES AND THE 
SURGICAL TREATMENT OF MENTAL DISEASES 

A statistical review of the causal relationship between head injuries 
and mental diseases compiled from various observers shows that 
insanity is ascribable to head injury in about 3 per cent of the cases. 
Perhaps the work of English^ is the most illuminating in this connec- 
tion, available at this time. Injury to the head of the infant during 
birth is probably responsible for the largest number of cases. It is 
true that severe deformity of the fetal head is in most instances com- 
pletely recovered from. When, however, the birth injurj^ is responsi- 
ble for a MENTAL DISTURBANCE, the latter always appears in the form 

OF IDIOCY and is MANIFEST DURING THE FIRST YEAR OF LIFE. Of COUrSC 

not all cases of congenital idiocy are due to head injuries. In arriving 
at a conclusion, the surgeon must take into account congenital chronic 
hydrocephalus, early meningitis, congenital cerebral defects, and 
microcephalus (Wulff,^ Vogt^). In the adult, the form of mental 
derangement following injury is inconstant and presents a number of 
characteristics. However, all of the psychoses present certain ele- 
ments in common, i. e., disturbances of memory and lack of mental 
concentration. 

The causative trauma may be a severe one, i. e., extensive destruction 
of the skull and its contents or a gunshot wound of the brain ; in other 
cases it may be so slight in degree that external evidences of injury 
are absent. A normal brain is capable of withstanding a severe 
injury, while one weakened by alcohol, etc., shows the evil effects of 
comparatively slight trauma. In all instances, the effect of trauma is 
expressed by unconsciousness, which results from concussion (commo- 
tion psychosis) . The anatomical lesion of these psychoses may consist 
in gross changes, such as hemorrhages, areas of softening, scars, trau- 
matic cysts, or in more minute changes, such as occur in the Mood 
vessels of the cortex in the form of transient and permanent dilatations 
of blood vessels, scleroses, punctate hemorrhages, infiltration of the 

1550 



SURGICAL TREATMENT OF MENTAL DISEASES 1551 

sheaths of the vessels, etc. The influence of all grades of trauma in. 
the production of psychoses has been recently studied by Roussy and 
L'Hermite* in connection with the world war. This presentation is 
worthy of perusal. These indefatigable workers recognize the influ- 
ence of predisposing factors, such as heredity, and lay especial stress 
on lues and alcohol. They also furnish a comprehensive bibliography 
pertaining to the subject. 

Lunacy after head injury may he divided into two groups. In the 
first, the ps^'chosis is immediately sequential to the injury, and in the 
second, it does not occur until a greater or lesser period of time has 
elapsed. 

In cases of the first group the injury is attended with severe con- 
cussion and unconsciousness, which lasts for a variable "period of time 
(often for weeks). When consciousness returns, the patient has no 
recollection of the injury and mcimory in general is especially distorted. 
A so-called traumatic retrograde amnesia is common, so that the 
patient does not recall events that happened before the injury; the 
past is, as it M^ere, "wiped out." WestphaP reports cases of definite 
forms of psychosis attended with aphasia, agnosia, and apraxia. In 
others, the patient is irritable, maniacal, has hallucinations, and is 
unable to sleep, a condition that Wille*' calls delirium traumaticum. 
As a rule, return to the normal occurs in three or four weeks, although 
permanent impairment of memory is not rare. 

A number of cases of acute traumatic psychosis present a clinical 
picture closely resembling the so-called Korsakoff symptom complex 
(Heilbronner,'' Kalberlah^), in which the patient is unable to fix his 
attention, memory is impaired, and appreciation of time and place is 
disturbed. In addition to this, the patient is easily excited, remembers 
things that did not happen (false memory), and attempts to supply 
something when he cannot remember. 'In this type the prognosis is not 
good and is worse when the primary stage of unconsciousness is imme- 
diately followed by a so-called posttraumatic dementia (Koppen"). 

In the second group of cases are those so-called soul disturbances 
which develop some time after infliction of the head injury. However, 
the actual appearance of the psychosis is often preceded by a prodromal 
period which is characterized by disturbances of sensation, changes in 
the patient's temperament and character, and lessening of mental 
capacity. . Of these, the changes in character and habits, in con- 
trast TO THE previous CONDITION, ARE MOST MARKED (TRAUMATIC PSY- 
CHOPATHIC constitution) . Peace loving persons become quarrelsome, 



1552 SURGERY OF THE HEAD 

moderate drinkers imbibe excessively, or are intoxicated by small 
quantities of alcohol. Many of these cases go on to secondary idiocy, 
others develop melancholia, catatonia or mania. The causative rela- 
tionship between the injury and the second group of cases is certain, 
if the prodromal stage has been presented and this is attended with 
clearly defined brain symptoms (Kiittner^"). 

The class of cases in which a head injury is slight and simply 
renders the individual more susceptible to the development of a 
psychosis cannot be discussed here. It is, however, proper to state 
that a relationship of this sort is of clinical significance only when 
a distinct connection between the injury and disturbances of the 
sensorium can >be shown. 

Injuries of the head have been held responsible for general progres- 
sive paralysis. Modern, serological examinations seem to have shown 
that injury of the skull of the non-luetic is not followed by general 
paresis; on the other hand, it is not improbable that injury of the 
skull in a luetic is followed hy an exacerhatioji of the paretic condition. 

It occasionally happens that a patient w^ho has apparently com- 
pletely recovered from a head injury and is again- ' ' engaged in the 
contest of life" will gradually develop certain disturbances grouped 
under the head of "traumatic neurosis." The genuine traumatic 
neurosis is characterized by so-called brain symptoms, i. e., headache, 
vertigo, mental depression, lack of ambition, lack of concentration and 
impairment of memory. The patient is likely to complain of palpita- 
tion of the heart and dizziness, especially when he "bends over." In 
some of these cases lumbar puncture has revealed increased cerebral 
pressure which would indicate an underlying pathological causation. 
In others, the symptoms are purely functional (vasomotor). Accord- 
ing to Kiittner,^° traumatic neuroses of the latter sort occur most 
frequently in individuals deeply concerned in the award of a disability 
pension and when the award is made the condition usually disappears. 

The operative treatment of traumatic psychosis has been frequently 
attempted. Unquestionably favorable results have been obtained in 
cases of psychic epilepsy (Heidenhain^^). This is also true of cases of 
progressive idiocy following epilepsy in children (Krause^-). The 
technic consists in the osteoplastic repair of cranial defects (p. 1567), 
the removal of cicatrices, cysts and tumors of the brain. Linear 
cranial resection enjoyed only a brief period of popularity .(Koppe," 
Schiiller," Borchardt,^^ Semelaigne^®). 



SURGICAL TREATMENT OF MENTAL DISEASES 1553 

BIBLIOGRAPHY 

1. English, Lancet, i, 1904. 

2. WuLFP. Allg. Zeitsc'ir. f. Psychiat. xlix. 

3. VOGT. Epilepsie im Kindesalter, Berlin, 1911. 

4. KoissY and L'Hermite. Med. and Surg. Theraj). ii, X. Y. and London, 

1918. 

5. AVestpiial. Arch. f. Psychiat., 1910, xlvii. 
G. WiLLE. Arch. f. Psychiat., viii. 

7. IlKii.r.KOXXER. Miinch. med. "Woch., 1905, Xos. 49, 50. 

8. Kalbehlah. Arch. f. Psychiat., 1904, xxxviii. 

9. Koppex. Arch. f. Psychiat., 1900, xxxiii. 

10. Klttxer, in Handh. d. prakt. Chir. i, 1913. 

11. Heidexhaix. Fortschr. d. med., 1896, No. 3. 

12. Krause. Surg, of the Brain, etc., N. Y., 1909. 

13. KOPPE, Deutsch. Arch. f. klin. ^led. xiv. 

14. ScHiJLLER. Leipziger Dissert., 1882. 

15. BORCHARDT. Berlin Dissert., 1893. 

16. Semelaigxe. Ann. med-psychologiques, 1895. 



CHAPTER X 

THE SUEGICAL TREATMENT OF BRAIN TUMORS 

As the outcome of the collaboration of the neurologist and the 
surgeon the localization of a brain tumor is verified by operative 
exposure in 75 per cent of the cases (Bruns^). Of these, it is possible 
radically to remove only a certain number. 

Tumors of the brain are divided as follows : 

1. Genuine tumors. 

(a) primary. 

(b) secondary. 

2. Granulation tumors. . 

(a) tubercle. 

(b) gumma. 

(c) actinomycosis. 

3. Diseases of Mood vessels attended with the clinical picture 

of tumor. 

4. Cysts. 

5. Parasitic cysts. 

Of the genuine tumors, glioma and sarcoma are the most common 
(Allen Starr^). Their histology is taken up in Part VI (see also 
Oppenheim,^ Starr,^ Henschen,* Kiittner,^ Auvray®). Psammoma is 
regarded as a form of sarcoma (p. 1290). 

Enchondromata, lipomata, dermoids, and teratomata are rare 
tumors of the brain. Angiomata are taken up on page 1158. 

Of the granulation tumors, conglomerate or solitary tubercle is by 
far the most common. Starr- says "they form 50 per cent of all 
tumors of the brain in children." Gumma is more common than is 
histologically proved. Oppenheim^ explains this on the ground of 
their frequent spontaneous disappearance. Actinomycosis is very rare 
(see page 404). 

Diseases of Mood vessels that provoke the clinical picture of tumor 
belong to the class of telangiectases, cavernous and racemose angio- 
mata (Krause^). 

1554 



THE SURGICAL TREATMENT OF BRAIN TUMORS 1555 

Cysts of the brain are frequently the outcome of degenerated genuine 
tumors; true cysts also form in this situation (for instance, a dilated 
fourth ventricle may provoke the symptoms of a tumor of the acusti- 
cus). Cysts of the pia develop occasionally after trauma, or are 
inflammatory or syphilitic in origin {meningitis chronica circum- 
scripta serosa). The accumulation of fluid in the posterior cistern 
ma}' be mistaken for a cyst formation. 

Parasitic cysts appear in the form of the cysticercus cellulose and 
eckinococci. They are usually multiple and may be located in any 
portion of the brain. 

The etiology of tumors of the brain is as little understood as is that 
of new growths in general (p. 109-4). The influence of trauma is of 
practical importance. In tubercle and gumma, trauma is not the 
direct cause, but may determine localization of the process, on the 
locus minor theory. That trauma is responsible for the formation 
of a genuine tumor is highly improbable; the injury may call atten- 
tion to its presence. On the other hand, injury may be responsible 
for the cyst formation and for basal aneurism. 

Of the symptoms of brain tumor it may be said, that while a tumor 
may be present in the brain and life complete its cycle without the 
development of symptoms ascribable to the new growth, as a rule the 
presence of the lesion is evidenced by more or less typical disturbances 
of brain function. 

The general symptoms are in no sense in accord with the size of the 
tumor. The}' appear especially early in growths involving the pos- 
terior cranial fossa ; on the other hand, those located in the central 
convolutions and pons do not provoke sjonptoms until they attain 
considerable dimensions. 

The general sjTnptoms may be divided according to their clinical 
importance as follows: (1) headache; (2) choked disk (disturbances 
of vision) ; (3) psychoses; (4) convulsioiis ; (5) vertigo; (6) vomit- 
ing; (7) changes in pulse and respiration. 

Headache is probably never absent, although the presence of brain 
'tumor has been established before this symptom developed (Horsley^). 
"While the headache is constant, violent exacerbations are frequent and 
these are often attended with befogged consciousness. An exacerba- 
tion, i. e., congestion of the brain, may be precipitated by alcohol, 
mental excitement, coughing, defecation (Bruns^). The character 
of the headache is described as dull and boring, and may be localized 
or general. A violent attack of headache may be provoked hy percus- 



1556 SURGERY OF THE HEAD 

sion of the skull. In some instances percussion elicits a tympanitic 
note {bruit de pot file of Bruns^), which is regarded as indicative of 
thinning of the cranial bones, and often corresponds to the site of the 
new growth. 

Choked disk is of especial value in the diagnosis of tumor of the 
brain in all stages of the lesion and is rarely absent. Vision itself need 
not be impaired, but gradually this is also affected and is attended 
with scintillations alternating with periods of darkness. Blindness 
occurs late but may appear suddenly, and unfortunately usually 
affects both eyes. In tumors of the cerebellum, choked disk appears 
very early, while changes in the optic nerve may be absent. 

In the early stages of tumor development ps?/c/iic disturhances are 
not marked, but later on they become more clearly defined. Of these, 
mental hebetude is the most marked. The patient does not evince 
interest in his surroundings and responds to inquiries only when they 
are persisted in. Soranolence is a frequent symptom and the facial 
expression is usually stupid. In a certain number of cases genuine 
psychoses are developed (melancholia, delirium, and mania). How- 
ever, Bruns^ and others hold that in these instances the tumor simply 
precipitates a latent psychosis. Psychoses are not dependent upon 
the seat nor upon the character of the tumor, but are most likely to 
develop in connection with growths attended with hydrocephalus 
interna. However, not a few authors regard the development of 
psychoses as indicating a lesion of the frontal lobes (see Oppenheim^). 

Convulsions occur in 25 to 30 per cent of cases of brain tumor 
(Bruns^). They are likely to resemble genuine epilepsy, so that the 
affected persons may be regarded as epileptics for years before the 
diagnosis is made. The seizure closely resembles jacksonian epilepsy 
in character. 

Vertigo is an inconstant and not very helpful s;>Tnptom in tumor of 
the brain and is rarely present in its genuine rotary form, except in 
lesions involving the vestibule, the acusticus, pons, medulla, and the 
fourth ventricle. In these instances it is usually associated with 
nystagmus. The feeling of dizziness is increased by changes of posture 
.and, when the head is suddenly passively moved, the patient is likely 
to fall (Bruns^). According to Hitzig," tumors of the frontal lobes 
may be attended with vertigo. 

Vomiting may be regarded as an expression of general cerebral 
pressure. In tumors of the cerebellum emesis is ascribable to direct 
irritation of the ''vomiting center." Despite the vomiting, the appe- 



THE SURGICAL TREATMENT OF BRAIN TUMORS 1557 

tite continues g:0'od. Its concurrence with headache causes confusion 
with nephritis. Kuttner'^ relates an instance in which he was asked 
to decompress a case of this sort, but fortunately the diagnosis of 
nephritis was established in time. 

Sloiving of the pulse is a vagrant symptom of brain tumor. Oppcn- 
heim^ says that rapid pulse is as frequent as a slow one, except, of 
course, when general cerebral- compression is established. Distinctive 
respiratory disturbances develop only in tumors of the posterior cranial 
fossa and then consist in the arhytlimia and the Cheyne-Stokes type. 
Additional general symptoms are those of general cerebral pressure. 

The focal symptoms of brain tumor relate to the disturbances of 
function consequent to destruction of sectors of brain and the damage 
done to the tissues contiguous to them. The symptoms thus produced 
are either the result of an immediate influence on brain tissue or of 
remote or distal disturbances. While the former are of distinct diag- 
nostic value, the latter often lead the surgeon astray. The effect of 
the destruction of definite regions of the brain is taken up on p. 1520. 

Although, as a rule, a case of brain tumor comes to the surgeon 
after the diagnostic problem has been studied by the neurologist, the 
ophthalmogist, and the otologist, it is necessary that the findings thus 
obtained be carefully weighed ; and their application to the surgical 
problem from the surgeon's standpoint must decide the feasibility and 
the justification of making operative efforts at relief. In recent years 
the Rontgenogram and the employment of brain puncture have been 
found of great assistance in recognizing the presence and location of 
brain tumors. The radiogram has been of signal service in connection 
with tumors of the hypophysis, and Henschen* reports that in cere- 
bellopontian tumors, widening of the bony canals of the internal ear 
has been recognized in the same way. 

The Neisser-Pollack^° brain puncture gives positive evidence, not 
only of the site, but also of the character, of the tumor. The pro- 
cedure is not without certain elements of danger, but these are not 
"unsurmountable. The value and the dangers of lumbar puncture are 
already taken up (p. 1414). Neither Cushing^^ nor Borchardt^^ punc- 
tures the spine in these cases, unless the skull is opened, a precaution 
to which the writer has already alluded and herewith reiterates as 
imperative. Distention of the cerebral ventricles with air and subse- 
quent radiography {ventriculography), recently introduced by 
Dandy,^^ seems to possess considerable value. 

In the treatment of tumors of the brain, medicinal therapy, even of 



1558 



SURGERY OF THE HEAD 



the palliative form, is of restricted value, with perhaps the exception 
of gumma. In this connection, the surgeon is warned that diagnostic 
antiluetic treatment must not permit time — valuable to operative 
methods of relief — to be wasted, especially as temporary improvement 
of symptoms has followed antisyphilitic medication in cases of genuine 
brain tumor (Oppenheim,* Redlich"). As far as salvarsan is con- 
cerned, the writer can only reiterate the warning sounded by Ehrlich,^^ 
that its employment in cases of brain tumor is likely to do great harm. 
Headache is relieved only by 'opiates. 

The gejieral technic of the extirpation of hrain tumors is similar to 
that of trephining (p. 1563). The question of the one or two stage 
operation may be answered in 
favor of the latter, except when 
the tumor is extradural or in 
eases in which the lesion is diag- 
nosticated very early and cere- 
bral pressure is not marked. In 
this connection the statistical 
data furnished by Krause'^ are 
instructive. 

The special considerations that 
must be impressed upon the 
student in eonnection with the 
technic of operative attack upon 
tumors of the brain relate to the 
posture of the patient, the selec- 
tion of the anesthetic, and the 
method of opening the skull. 
The dura is usually opened in 

the form of a flap. When the tumor is located, it is removed with a 
dull spoon. 

Subcortical tumors present especial difficulties, although their pres- 
ence may be revealed by elevation of the cortex, by flattening of the 
convolutions, and by obliteration of the sulci. Palpation is not of 
great aid, needling may be ; and while removal of a cylinder of tissue 
for immediate microscopical examination is determining, incision of 
course is certain. 

Extirpation of the tumor is followed by more or less bleeding; it is 
usually considerable. Divided vessels are ligated, but this must be 
done with as little trauma to the brain tissue as possible. Transient 




Fig. 750.- 



- Tumor of the Cerebello- 
pontine Angle. 



I 



THE SURGICAL TREATMENT OF BRAIN TUMORS 1559 

lami)()nade of the cavity (iodoform gauze) is often necessary; the 
gauze must be inserted witli just enough pressure to arrest the bleed- 
ing. The dura should be sutured into place when possible. 

Exposure of the posterior cranial fossa, because of the relative fre- 
quency of tumors in this region deserves special mention. At the 
present time the operation is frequently performed under local anes- 
thesia. Krause'^ and Borchardt^^ employ the osteoplastic method 
(Fig. 752) ; Kiittner, and not a few others, sacrifice the bone. The 
former technic is desirable but involves greater danger of injury to 
the medulla than does the latter. 

Decmnpressive trephining as a palliative measure of relief in inope- 
rable tumors of the brain is an established procedure. The operation 
consists in opening the skull and the dura. Most surgeons sacrifice 
the bone ; Krause^ fashions an osteoplastic flap, outlining it by means 
of wide liberating bone sections. In either event, the edges of the 
bone should be covered with dural flaps in order to prevent laceration 
of the brain, which immediately protrudes through the opening of the 
skull. When the tumor is located, the opening is made over it. In 
other instances the skull is entered over the left temporal lobe in left 
handed people, and over the right in right handed people. Gushing" 
advocates subtemporal decompression. In lesions of the cerebellum 
the posterior cranial fossa may be decompressed in the manner 
employed for approaching this area for other purposes. 

BIBLIOGRAPHY 

1. Bruns. Die Gesehwiilste des Nervensyst., Berlin, 1913, with lit. 

2. Allen Starr. Brain Surgery, 1894, with lit. 

3. Oppenheim. Nothnagel's Spec. Path., etc. (2d ed.), 1902. ' 

4. Henschen. tjber Gesehwiilste d. hint. Schadelgrube, etc., Jens, 1910, 

and Fortschr. a. d. Gebiet. d. Rontgen., 1912, xviii, with lit. 

5. KiJTTNER, in Handb. der prakt. Chir., Stuttgart, 1913. 

6. AuvRAY. Les tumeurs cerebrales, Paris, 1896. ~- 

7. Krause. Surg, of the Brain, N. Y., 1909. V 

8. HORSLEY. Brit. med. Jr., 1906. 

9. HiTziG. See lit. No. 1. 

10. Neisser-Pollack. Handb. d. Neurolgie, i, with lit. 

11. Gushing. Surg. Gyn. Obst., 1905. 

12. BoRCHARDT. Pavr-Klittner, Ergeb. d. Chir., etc., ii, with lit. 

13. Dandy. Surg. Gjti. Obst. xxx, 1920. 

14. Redlich. Same as No. 10. 

15. Ehrlich. See lit. of No. 4. 



CHAPTER XI 
THE SUKGERY OF THE HYPOPHYSIS CEREBRI 

The first operative attack upon the hypophysis in the human was 
made by Horsley^ in 1906 ; the subsequent surgery of this mystifying 
organ is based on the work of Schloffer.^ 

A detailed discussion of the functions of the hypophysis is of course 
impossible here. The conclusions of Gushing^ may be regarded as 
authoritative in this connection. They may be briefly stated as follows : 
The hypophysis is essential to life ; its total extirpation is followed by 
death ; so is excision of its anterior lobe alone ; removal of the pos- 
terior lobe alone is not followed by serious results. Partial removal of 
its anterior lobe leads to peculiar disturbances, i. e., adiposis, sexual 
regression, polyuria and glycosuria ; these are similar to the conditions 
attendant upon tumors of the gland and are designated in the literature 
by the term dystrophia adiposog enitalis. Fituitrin is derived from 
the posterior lobe. Extracts from the anterior lobe do not seem to 
possess the value of those of the posterior. The "physiological cor- 
relation" of the pituitary body and other internal secretion glands 
(thyroid, testicle, ovary, etc.) is still a subject of investigation. Its 
clinical significance is already shimmering on the horizon (see bibli- 
ography of Melchior* and the experimental work of Crowe, Cushing 
and Homans^). 

Of the lesions of the hypophysis, only the tumors are of importance 
to the surgeon. These are divided into two general groups, the 
adenomata, and the so-called tumors of the hypophyseal anlage of 
Erdheim.^ The latter represent an especial form of epithelial growth, 
partly carcinomatous in character, and originate from displaced 
embryonic elements. Adenomata of the hypophysis are benign tumors 
responsible for the clinical picture generally known as acromegalia 
(p. 1073). On the other hand, the embryonic tumors of Erdheim" are 
regarded as standing in a causative relationship to dystrophia adiposa- 
g enitalis (Frohlich'^). 

The local symptoms of tumors of the hypophysis relate primarily to 

1560 



THE SURGEKY OF THE llYPOPHYSliS CEKEBlil 1561 



disturhanccs of vision due to pressure on the optic chiasm, of which 
narrowing ol' the temporal field of vision is regarded as typical 
{biteinpoi'al hemi-aiiopsia). Tliis is usually associated with progres- 
sive amblyopia, the outcome of optic nerve atrophy, which ultimately 
goes on to complete amaurosis. Choked disk is not an essential symp- 
tom, nor is paralysis of the motor nerves of the eyeball common (see 
IJlitoff,* KanaveP). Headache is a constant symptom (Frankl-Hoch- 
wart^"). In some instances, persistent hydrorrhea developes (Kiitt- 




FiG. 751. — Hypophysectomy (Kanavel). 

ner^^). The Wont genog ram, which reveals enlargement of the sella 
turcica, is of great value. 

The general trophic disturhanccs of hjT)ophyseal tumors belong in 
part to the domain of acromegalia and in part to dystrophia adiposo- 
genitalis. In acromegalia, trophic disturbances m.a.y be absent 
(Uhtoff^), According to Benda,^- acromegalia is the outcome of 
hyperfunction of the gland, while dystrophia adiposogenitalis is the 
result of hypopituitarism. 



1562 SURGERY OF THE HEAD 

The indication for operative effort at relief is based on the local 
symptoms, especially impairment of vision. 

Schloffer^ turned the nose aside; v. Eiselsberg^^ elevated the nose 
and approached the gland through the frontal sinuses; Gushing^ also 
formed a frontal osteoplastic flap. Recently, KanaveP raised the nose, 
resected the septum and gained access to the sphenoid from below 
{infranasal route). Figure 751 gives an adequate notion of the last 
method. The endonasal method of Hirsch" is ingenious and no doubt 
is readily accomplished by an expert rhinologist. Of fourteen cases, 
only two died. The improvement following the operation in cases of 
acromegalia is likely to be little short of startling. 

BIBLIOGRAPHY 

1. HoRSLEY. British Med*. Jr., 1906. 

2. ScHLOFFER. Wiener klin. Woch., 1907, No. 21. 

3. Gushing. Anns. Surg., Phila., 1910, lii. 

4. Melchior. Ergeb. d. Chir., etc., v. Payr and Kiittner, 1911, iii, 

with lit. 

5. Crowe, Gushing and Homans. Johns Hopkins Bull., 1910. 

6. Erdheim. Sitzungsbericht d. k. Acad., Sect, iii, Vienna, 1904. 

7. Frohlich. Same as No. 4. 

8. Uhtoff. Handb. d. Augenheilk (Graf-Samisch) (2d ed.), 1911. 

9. Kanavel. Surg. Gyn. Obst., Jan., 1918. 

10. Frankl-Hochwart. Wien. med. Woch., 1909. 

11. KtJTTNER, in Handb. d. prakt. Ghir. i, Stuttgart, 1913. 

12. Benda. Handb. d. path. anat. des Nervensystem, von Flatau-Jaeobsohn, 

ii, Berlin, 1904. 

13. V. Eiselsberg. Anns. Surg., Phila., 1910, lii. 

14. HiRSCH. Arch. f. Laryng., 1910, xxiv. 



CHAPTER XII 

THE TECHNIC OF TREPHINING, BRAIN PUNCTURE, RESECTION OF 
THE SKULL, CRANIECTOMY, CRANIOPLASTY AND DURAPLASTY 

In recent years the efforts of a number of surgeons have been devoted 
to devising methods of invading the cranial skull, with the result that 
"the classic operation of trephining with its instrumentarium, inher- 
ited from the dark ages of several centuries ago, has quite properly 
been relegated to history" (Kiittner^). As a rule, the cranium is 
opened for the purpose of applying measures of relief to its contents 
and the opening in the bone is made as close to the site of the lesion 
as is possible. Occasionally, removal of a sector of the skull is essen- 
tial for the purpose, but ordinarily this is unnecessary unless the bone 
itself is injured or diseased. The latter class of ca.ses includes primary 
and secondarj^ resection of splinters of bone and excision of bone 
tumors, tuberculosis, lues, etc. 

Therefore, for the purpose of applying intracranial methods of , 
relief, the approach is accomplished by the so-called temporary or 
osteoplastic resection of the skull originally devised by Wagner^ and 
carried to its greatest extent by Doyen^ {hemicraniectomy) . 

The technic of opening the skull may be divided into the following 
groups : 

1. Simple drilling of the skull. 

2. Simple resection of the skull. 

a. The classic trephiyiing with the trephine. 

b. Chisel resection. 

3. Osteaplastic resection of the skull. 

a. The method of Wagner. 

b. The method of Doyen and allied methods. 

c. The method of Toison and Ohalin^ki. 

Simple Drilling of the Skull. — Simple drilling of the skull is done 
for the following reasons: (a) to withdraw fluid from the ventricles; 
(b) for intraventricular medication; (c) for diagnostic purposes. The 
last has been developed by Neisser and Pollack.* At this time intra- 

1563 



1564 



SURGERY OF THE HEAD 



cranial medication is restricted to the injection of antitetanus serum. 

The technic of the procedure is simple. Most surgeons use an 
electrically driven drill. In order not to have to grope for the drill 
hole, Gotze'^' bores the skull with a "gutter drill' and uses it as a 
guide for a thin wire; the hollow tube is introduced over the wire. 
The puncture is occasionally followed by a pial hemorrhage. How- 
ever, this is rare. 

Simple Resection of the Skull. — In simple resection of the skull, the 
classic trephine is used only when a definite object is to be attained 
and when this may be accomplished through a small opening in the 
skull (2.5 to 3 cm.). Kronlein*' ardently supports the use of the 
trephine for ligature of 
the middle meningeal artery 
and in cases of sharply de- 
fined lesions of the bone, 
such as punctured fractures. 
The means by which the 
trephine is operated is im- 
material. 

Resection with the chisel 
is employed in the same con- 
ditions as is the trephine. 
At the hands of the skilled 
technician it possesses a dis- 
tinct field of usefulness. 
However, the concussion co- 
incident with the use of the 
mallet is objectionable. 

Osteoplastic Resection of the Skull.— Osteoplastic resection of the 
skull is the method of choice for the purpose of draining an ahscess, 
extirpation of a tumor, removal of a foreign T)ody, and exposure of an 
epileptogenous focus. 

The essential steps in the technic consist in incising the scalp and 
periosteum in the outline of a flap ; this is followed by section of the 
bone in the line of the incision in the soft parts. The osteoplastic flap 
thus outlined is then fractured at its base and the parts turned down 
(Fig. 752). Various methods of dividing the bone have been devised. 
The primary opening of the skull which permits the introduction of 
bone cutting instruments may be accomplished by means of the Doyen' 
"fraise spherique" already described (p. 787). Of the liand driven 




Fig. 



752. — Exposure of the Cerebellum by 
THE Osteoplastic Flap Method. 



THE TECHNIC OF OPENING THE SKULL 1565 

bone cutting tools in use today, the Dalilgreu^ craniotome (Fig. 753). 
is the most satisfactory. Perhaps the "last cry" in this connection is 
the electrically driven "automatic trephine" of de MarteP (Fig. 754). 




Fig. 753. — The Original Dahlgren Craniotome. 



This ing 
openings 



Fig. 754 



enious instrument makes the necessary number of primary 
in the skull and is so arranged that injury to the underlying 

dura is impossible. The bone flap 
is then cut with the spiral osteo- 
tome (a modification of SudeckV 
device) (Fig. 755), which is used 
in connection with the same appa- 
ratus. The motor is described on 
page 784. The rotary circular 
saiv of Salzer,^° extensively used 
by Doyen,^ is an effective instru- 
ment but is difficult to control. 
When the three sides of the bone 
flap are cut, its base is fractured 
by means of a periosteal elevator 
or other suitable bone lever. It is 
permissible to add that special 
bone cutting instruments that 
meet the particular notions of the 
surgeon are readily constructed 
when the principle of the pro- 
cedure is borne in mind and an 
electric motor is available. For 
instance, Borchardt^^ uses a sort of 
"bone plow" to cut the external 

, . table and completes the section 

■ DeMartet/s Automatic .,■,,■, o. j i q • i „+^^4.^ ^ 

Trephine. With the Sudeck** spiral osteotome ; 




1566 



SURGERY OF THE HEAD 



Krause^^ uses the Dahlgren' eraniotome entirely and regards electri- 
cally driven instruments as a ''fad." It is certainly unwise to be 
entirely dependent upon them. Most surgeons use a spherical burr 
for the purpose of making the primary openings ; yet this is readily 
accomplished with a small trephine. 

Toison^^ of Lille (1891) is responsible for the use of a flexible sajv 
which divides the "skull from within. This was soon displaced by 
Obalinski/* who showed that the Gigli^° wire saw was better adapted 
to the purpose. Although the danger of injury to the dura and the 
brain involved in the use of the wire saw was largely overcome by the 
interposition of various materials (Braatz/® Lauenstein/^ and Gigli^''), 
the method fell into disuse. However, recently de IMarteP reports 
having used it in a number of cases. Most American surgeons use 
the spherical burr of Doyen^ for making the primary 
openings in the skull and cut the bone with the 
Dahlgren" (called De^albis in this countrjO eranio- 
tome ; or the de MarteP trephine and spiral osteotome 
driven by the electric motor previously described are 
used throughout. The latter is used in all well 
equipped hospitals. 

Bleeding from the scalp may be controlled in a 
number of ways. These include the use of the 
KredeP^ plates, the Heidenhain" sutures, and the 
specially constructed clamps of Makkas.-" The last 
are most satisfactory and have dislodged the first 
two from most clinics. 

Bleeding from the emissaries and the veins of the 
diploe may be arrested by the introduction of wooden or ivory plugs, 
or Horsley's wax may be used (p. 42). Crushing the open vessel in 
its bony bed with a rongeur or a sharp blow with a mallet often 
accomplishes the purpose. Krause^- uses an especially constructed 
bone hook; Sauerbruch-^ applies negative pressure to the body, thus 
lessening the quantity of blood in the brain. 

The Closure of Cranial Defects. — Notwitlistanding a few recorded 
instances (of doubtful accuracy), defects in the skull do not undergo 
spontaneous ossification. In addition to this, the connective tissue 
repair is not of sufficient strength to afford, in anj'- sense, the protec- 
tion to the cranial contents necessary to its welfare (Kiittner^). Not 
the least objectionable feature of the presence of a defect is the trauma 
that the unprotected brain substance is constantlj^ suJbjected to as a 




Fig. 755. — Spirai, 
Osteotome. 



THE TECIINIC OF OPENING THE SKULL 



1567 



part of the ordinary activities of life (Koenig'--). It is, therefore, 
incumbent upon the surgeon to prevent the occurrence of defects and 
to repair them when present. The first effort of this sort is recorded 
by Koenig^- (1890), who closed a large defect in the skull (traumatic) 
b^^ means of a pedunculated skin-periosteal-lamina-externa flap derived 
from the contiguous skull. Miiller-'"' had advised the use of the 
method in lieu of the osteoplastic craniectomy, and for this reason the 
term "M'uller-Koenig osteoplastic flap method" is used in the litera- 
ture. The value of the procedure is unquestioned, not alone in trau- 
matic cases, but also in congenital defects and in the repair of loss of 
substance seciuential to disease (tumors, tuberculosis, lues, etc.). The 
flap is fashioned in accord with the general principles of plastic 




OjrtoPiAiTic rtuP 



Fig. 756. — Osteoplastic Eepair of Defect in Skull. 



surgery and is best separated by means of a broad, thin chisel ; or a 
fine, thin, flexible saw may be used. 

Cranial defects have been closed by many other means with varying 
success. Of these the following are employed more or less frequently : 

Keimplantation of the excised trephine disk ; reimplantation of 
small fragments of bone; implantation of bone derived from various 
sources, such as the tibia of the patient, that of another person, or that 
of one of the lower animals ; implantation 'of decalcified bone ; implan- 
tation of boiled and raw untreated dead bone; implantation of metal 
and celluloid plates and the implantation of filigree net (see 
Kiittner^). 

DurapJasty. — Plastic repair of dural defects is made with a view to 



1568 SURGERY OF THE HEAD 

obviating adlierence of the brain to the soft parts. The following 
table of the various materials employed for the purpose is taken from 
Kiittner^ : 

A. Alloplastic — 1. rubber, gutta percha; 2. celluloid; 3. gold; 
4. silver ; 5. platinum. 

B. Heteroplastic — 6. egg membrane; 7, fish bladder; 8. wall of a 
blood vessel. 

C. Homoplastic — 9. peritoneum. 

D. Autoplastic — 10. periosteum; 11. fascia; 12. fat; 13. skin. 
The relative value of these agents is not defuiitely established. It 

would seem, however, that, as is the case in all plastic surgery, auto- 
plastic methods hold out the best hope of success, and of these the 
implantation of a free fascia and fat transplant is perhaps the most 
satisfactory (v. Eisels^berg-*). The recent contribution of Briining,^^ 
who separates a layer of the contiguous dura by injecting it with salt 
solution and folding the outer layer over the defect, is worthy of con- 
sideration. It is said to be easily carried out for the purpose of closing 
small defects, 

BIBLIOGRAPHY 

1. KtJTTNER, in Handb. d. prakt. Chir., Stuttgart, 1913. 

2. Wagner. Zentrbl. f. Chir., 1889, No. 47. 

3. Doyen. Congres franeais de chir., Paris, ix, 1895, and x, 1896; Tech- 

nique ehirug., Paris, 1897; Arch. f. klin. Chir. Ivii. 

4. Neisser-Pollack. Handb. d. Neurol, i, with lit. 

5. GOTZE. Deutsch. med. Woch., 1912, No. 7. 

6. Kronlein. Deutsch. Zeitsehr. f. Chir. xxiii. 

7. Dahlgren. Zentrbl. f. Chir., 1896, No. 10. 

8. DE Martel. Med. and Surg. Therap. iii, N. Y. and London, 1918. 

9. SUDECK. Arch. f. klin. Chir., 1900, Ixi. 

10. Salzer. Wiener klin. Woch., 1889, No. 49. 

11. BoRCHARDT. See No. 12. 

12. Krause. Surg, of the Brain, etc., i, 1909. 

13. ToiSON. V. Congres franeais d. chir., Paris, 1901, No. 26„ 

14. Obalinski. Zentrbl. f. Chir., 1897, No. 32. 

15. GiGLi. Zentrbl. f. Chir., 1898, No. 16. 

16. Braatz. See Krause No. 12. 

17. Lauenstein. Zentrbl. f. Chir., 1898, No. 8. 

18. Kredel. See Krause No. 12. 

19. Heidenhain. See Krause No. 12. 

20. Makkas. Zentrbl. f. Chir., 1910, No. 49. 

21. Sauerbruch. Zentrbl. f. Chir., 1909, No. 47. 

22. KOENIG. Zentrbl. f. Chir., 1890, No. 27. 

23. MiJLLER. Zentrbl. f. Chir., 1890, No. 4. 

24. V. EiSELSBERG. Chir. Kong. Verb., 1895. 

25. Bruning. Deutsch. Zeitsehr. f. Chir. cxiii. 



CHAPTER XIII 

CEANIOCEREBRAL TOPOGEAPHY 

The relationship the regions of the brain bear to the surface of the 
skull varies with age, size, sex, and race of the individual, and is, 
therefore, not susceptible to exact mathematical laws. To the surgeon 
this means that in invading the brain, he must expose sufficient of its 
surface to allow for these variations. When, in accord with certain 
topographical rules, the site of bone section is determined and the 
brain is exposed, further information as to the identity of certam 
areas is obtainable by means of electrical stimulation of the cortical 
areas (see Krause^). 

Topographical location is based on the determination of the situation 
of the central fissure and the fissure of Sylvius with respect to the 
surface of the skull. A number of methods have been devised for the 
purpose. Of these, the one of Kronlein,^ known as the Kronlein 
construction, based on the studies of Froriep,^ is the simplest and most 
satisfactory. « 

The lines upon which the construction is based are as follows (Fig. 
757): 

1. The hase line — linea horizontalis auriculo-orbitalis. 

2. The upper horizontal — linea horizontalis supraorbitalis. 

3. The anterior vertical — linea verticalis zygomatica. 

4. The middle vertical — linea verticalis articularis. 

5. The posterior vertical — linea verticalis retromastoidea. 

6. The linea Rolandi (oblique). 

7. The linea Sylvii (oblique). 

The points of orientation for the projection of 1 to 5 are as fol- 
lows: 

1. The base line through the inferior rim of the orbit and the 
upper edge of the meatus auditorius. 

2. The upper horizontal through the superior edge of the orbit, 
paralleling the base line. 

3. The anterior vertical from the middle of the zygoma, perpendicu- 
lar to the base line. 

1569 



1570 



SURGERY OF THE HEAD 



4. The middle vertical for the head of the inferior maxilla, perpen- 
dicular to the base line. 

5. The posterior vertical from the posterior edge of the base of 
the mastoid process, perpendicular to the base line. 

The two oblique lines are secondary and are drawn as follows: 

6. The linea Rolandi connects the point of junction of the anterior 




Z A M 

Fig. 757.— Diagram of Lines ant) Angles Constructed upon the Skull fob 
THE Location of the Convolutions and Fissures (Kronlein). 



CRANIOCEREBRAL TOPOGRAPHY 



1571 



vertical and tlie upper horizontal lines with the point where the 
posterior vertical crosses the vertex of the skull. 

7. The linea Sylvii bisects the angle formed between the linea 
Rolandi and the upper horizontal line and prolongs the line of bisec- 
tion posteriorly- until it crosses the posterior vertical line. 

In the construction (Fig. 757) this is indicated by: 




Fig. 758. — "Kronlein's Craxiometek. 



k. The point of bifurcation of the Sylvian fissure, 
s. Upper end of fissure of Sylvius, 
r. Lower end of the fissure of Rolando, 
p. Upper end of the fissure of Rolando, 
k.k. Kronlein's two sites for trephining, 
a.b.k.m. v. Bergmann's resection points. 

Outlining of the construction on the scalp is facilitated by the use 
of the Kronlein* craniometer shown in figure 758. 



1572 SURGERY OF THE HEAD 

BIBLIOGRAPHY 

1. Krause. Surg, of the Brain, etc., Berlin, 1913. 

2. Kronlein. Beitr. z. klin. Chir., 1898, xxii. ^ o u-j u i, 

3. Fporiep. Die Lagebeziehungen zwischen Grosshim and bcliadeldacli, 

Leipzig, 1897. 

4. Kronlein. ZentrbL f . Chir., 1899, No. 1. 



CHAPTER XIV 

THE SURGERY OF THE EAR 

Congenital Malformations of the External Ear. — Congenital malfor- 
mations of the external ear (excluding deviation from the artist's idea) 
are rare. Joseph^ classifies those susceptible of plastic correction as 
follows : 

I. Deformations of the ear. 

A. Ahnormal size of the ear (macrotia). 

1. Of the cartilage. 

2. Of the lobule. 

a. Abnormal width of the lobule. 

b. Abnormal length of the lobule, 
B, Ahnormal form of the ear of normal size. 

a. Flattening of the rim. 

b. Triangular ear. 

c. Fissures of the lobule. 
II. Malpositions of the ear. 

A. Abnormal protusions of the ear. 

1. With soft cartilage. 

2. "With hard cartilage. 

B. Rolling in of the ear. 
III. Adhesions of the ear. 

A. Synechia of the rim with the tragus. 

B. Synechia of the lobule with the cheek. 

Otomiosis is practiced for the purpose of reducing the size of the 
ear. Figure 759 shows a method which would seem sufficiently elastic 
to meet most contingencies. Reduction of the size of the lohule is 
easily accomplished by excision of a wedge shaped portion and suture. 
TTie triangular ear may be corrected in a similar manner. In fissure 
of the lohule the edges of the split are refreshed and apposed by 
suture. 

Ahnormal protrusion of the ear (otapostasis), when the cartilage is 

1573 



1574 SURGEliY OF THE HEAD 

soft, is easily overcome by removal of an elliptical sector of skin 
from the junction of the auricle with the scalp and suture of the 
wound. When the cartilage of the ear is hard, a sector of this tissue 
must also be removed (Keen,^ Koenig.^ See also bibliography of 
Joseph No. 1). 

Otosynechia is readily corrected by following the principles of plastic 
surgery already discussed (see Goldstein*). 

Paraffin therapy has been attended with so man}' accidents and is 
so frequently followed by unfavorable results that it has a very nar- 
row field of usefulness. 

Injuries of the Ear. — The exposed position of the auricle renders it 
particularly liable to injury. On the other hand, its vascularity and 





Fig. 759. — Eeduction of Otomegalia. 

the resistance on the part of the cartilage, explains the fact that 
wounds in this situation heal rapidly and are rarely infected. 

Contusions of the auricle are often followed by the formation of 
hematamata, which are peculiarly persistent. Repeated trauma causes 
grave deformation of the auricle (prize fighters, wrestlers, etc.). Pri- 
mary incision and e\'acuation of the extravasated blood has a tendency 
to prevent the deformity. 

Injuries of the external meatus are important because of the sub- 
sequent cicatrical stenosis. In this event, the secretions collect be- 
hind the obstruction and give rise ta serious disturbances ; the retention 
of a small quantity of material interferes seriously with hearing. In 
most instances some form of plastic operation is necessary for relief. 

Fractures of the articular surface of the maxillary joint may give 
rise to considerable bleeding and cause the formation of a hematoma 



THE SURGERY OF THE EAR 1575 

involving the external auditory canal. The introduction of hot fluids 
(acids, hot steam, etc.) may destroy the canal and drum and even 
gain access to the middle ear. In these instances, the area is so pain- 
ful that removal of the foreign substance must be accomplished under 
narcosis. 

Foreign bodies in the external auditory canal are often introduced 
by children (button, pea, bean, etc). However, occasionally, a por- 
tion of an instrument used for the purpose of removing wax is broken 
off and left behind. It is important that efforts at extraction of the 
foreign body do not force it still farther into the canal. Once the 
body is forced beyond the constriction where the cartilaginous and 
bony portions meet, extraction is difficult. In these instances the 
foreign body rests in the recess at the anterior medial part of the 
canal, and, if it is small (such as an insect), may be entirely hidden 
from view. 

When the foreign body is located in the cartilaginous canal, it may 
often be easily forced out by means of a gentle stream of warm water 
propelled by a syringe ; or the canal may be illuminated with a head 
mirror and a small dull hook used for the purpose. Narcosis is de- 
sirable. An astonishing amount of injury has been produced (even by 
physicians) by forcible efforts to remove foreign bodies from the ear, 
especially when exploration is made on the suspicion of the presence of 
the body. In these cases, the drum has been punctured and the bones 
of the middle ear "fished out" by mistake. The surgeon is admonished 
that a slight delay is not a disadvantage and that no effort should be 
made to remove the unwelcome visitor until proper conditions obtain, 
i. e., a good light, narcosis, and the proper instruments. When the 
foreign body is deeply located and cannot be removed by the means 
stated, it is best to nmke a curved incision behind the auricle, dis- 
place it forward and deliver the offending agent. It may be necessary 
to remove the posterior edge of the bony meatus. However, this is 
preferable to traumatizing the drum or worse. 

Injuries of the drum are the result of direct or indirect violence. 
Of the indirect injuries, those produced by sudden variations in air 
pressure, such as occur in connection with an explosion, a blow, a 
kiss, etc., are the most frequent. At times the drum is not entirely 
ruptured but is simply the site of a minute hematoma. The lesion 
has occurred as the result of sneezing or coughing, and occasionally 
follows forcible inflation of the middle ear (Politzer bag). A special 
form of rupture of the ear drum occurs in connection with diving into 



1576 SURGERY OF THE HEAD 

water, the water gaining access to the middle ear and provoking a 
more or less severe inflammation. In professional divers, enclosed in 
an air tight apparatus, the drum is ruptured as the result of the air 
pressure, especially when the eustachian tube is stenosed so that 
equalization of the pressure in the middle ear does not occur promptly. 
Rupture of the drum in connection with fractures of the base of the 
skull has already been taken up (p. 486). 

Injuries of the drum by direct violence are usually produced by the 
accidental or intentional introduction into the auditory canal ol 
various instruments, such as a toothpick, a wisp of straw, etc. Occa- 
sionally, an instrument is forced inward to the wall of the labyrinth 
and gains access through the foramen ovale to the labyrinth itself, or 
it may enter the cranial cavity through the tegmen tympani. Injury 
of the labj'rinth is immediately heralded by vertigo, nausea, and sub- 
jective disturbances of hearing. As a rule, the patient falls to the 
ground. After a few days or weeks, the more sitormy symptoms sub- 
side and, usually, ultimately disappear. Invasion of the labyrinth 
through an already infected middle ear is followed by serious inflam- 
mation of the former, which is likely to be fatal. When recovery en- 
sues, the hearing, on the injured side, is permanently lost. 

The diagnosis of ruptured tympanum is not always easy, at first, 
the collection of blood in the canal interfering with the examination. 
Removal of the blood by means of the syringe is not permissible. 
Excessive quantities of blood may -be gently removed with cotton 
wipes. When the bleeding has ceased and the danger of infection is 
over, the extent of the injury may be readily determined with the aid- 
of the speculum and the head mirror. 

The treatment of traumatic rupture of the ear drum is essentially 
that of noninterference ; even extensive lesions heal spontaneously. 
Meddling only interferes with repair. The normal mucosa of the 
middle ear is sterile, and, therefore, manipulations tending to force 
bacteria through the rupture into the former should be avoided 
(KiimmeF'). The ear should be lightly tamponed and the loose 
gauze plug frequently changed. It is perhaps wise to cover the ear 
with an aseptic protective dressing. When infectious meningitis de- 
velops, which is likely to happen when an already infected middle 
ear is traumatized, the cells of the antrum must be opened and free 
drainage provided for. 

Gunshot wounds of the ear are attended with grave disturbances of 
the auditory apparatus, especially when the projectile is fired di- 



THE SURGEKY OF THE EAR 1577 

rectly into the meatus. The labyrinth may be destroyed or merely 
placed out of function b}^ the concussion coincident with the injury. 
In the latter event, recovery from the disturbances ultimately ensues. 
In many cases the temporal bone is badly comminuted and the base 
of the skull presents fissures more or less remotely located from the 
site of the bullet ; the facial nerve is often destroyed or injured. 

As retention of the projectile is always, sooner or later, followed 
by suppuration, it should be removed. Determination of its exact 
location by means of the Rontgenogram is of great assistance. The 
technic of extraction may involve extensive surgical manipulations 
and the attempt should be preceded by a careful study of the prob- 
lem. 

Inflammation of the Ear Drum. — Inflammation of the ear drum 
usually occurs as a part of otitis externa or media. It is, however, 
subject to isolated inflammation in the course of acute infectious 
diseases, especially in association with so-called influenza (Kerrison" 
doubts this). This form of infection is called " myringiiis bullosa'* 
and is characterized b}^ the formation of small vesicles located upon 
various sectors of the membrane. The vesicles look like mother-of- 
pearl and contain a clear serum, at times mixed with blood. The con- 
dition must be diagnosticated from middle ear inflammation. The 
treatment consists in careful opening of the vesicle or vesicles. ' 

Acute Otitis Media. — Acute otitis media develops as a part of a 
general sj'stemic infection, or is due to the extension of an inflamma- 
tory process from the pharynx through the eustachian tube. Hema- 
togenous infection of the middle ear (Moos'^) occurs in association 
with all acute and chronic infectious diseases. The variation in the 
underlying causative factor probably accounts for the widely diver- 
gent character of the otic complication. There would seem to be no 
doubt that mild forms of otitis media without the formation of puru- 
lent exudate frequently occur. Whether these are bacterial in origin, 
or are simply due to obstruction of the eustachian tube, establish- 
ment of a vacuum in the middle ear, and the development of hydrops 
ex vacuo, is a disputed question (see Kerrison," Moos,^ Politzer.^ 
In any event, if the inflammation does not soon subside, the process 
taken on the form of a .purulent otitis media, which may go on to 
serious consequences. In these cases the drum, which, at first, is 
injected, and is violet in color, becomes red or copper colored ; pre- 
viously existing depression (caused by the vacuum in the middle 



1578 



SURGERY OF THE HEAD 



ear) is abolished and, as the exudate in the cavity increases, the mem- 
brane bulges perceptibly. The protrusion of the drum may be circum- 
scribed, being limited to its posterior upper quadrant, or may involve 
the anterior upper part (Shrapnell's membrane) alone. In the 
circumscnhed form, restitution to the normal is often effected. How- 
ever, perforation is not rare and may occur at the lower or at the 
upper aspect of the membrane. In the former event, evacuation of 
the exudate is followed by more rapid recover}' than is rupture of 
the upper sector. In the diffuse form the perforation may occur at 
any sector of the membrane and in severe cases multiple perforations 
are not uncommon. 

Of the symptoms, pain is the most dominant, even in mild cases ; it 
usuall}' begins suddenly and is likely to be very severe. It is de- 
scribed as boring, throbbing and stabbing in character, and radiates 





A B 

Fig. 760. — J, Normal Tympanuu. B, Perforated Tympanum (Eeik). 

to the temporal and mastoid regions. Tenderness over the entire 
r^ion, especially over the mastoid, soon develops. This is character- 
istic in children, in whom the disease is very common. The patient 
complains of "roaring, ringing, and pulsation in the ears;" occa- 
sionally loud noises cause pain and the spoken voice is reduplicated 
(autophonia). Audition is soon reduced. 

The general condition, in mild cases, is unaffected. As the process 
progresses, the clinical picture soon presents the characteristics of 
an acute infectious process. When the drum ruptures, the symptoms 
subside with astonishing rapidity, provided the opening establishes 
sufficient drainage. If, however, the perforation happens to be at 
the upper aspect of the drum, the symptoms are likely to recur. 

Tlie caurse of the disease varies widely. If suppuration does not 
occur, the process subsides in a few days ; if pus forms, the inflamma- 
tion may persist for weeks or longer. Not a few acute processes. Merge 



THE SUKGEKY OF THE EAR 1579 

into the chronic form of the disease. Kiimmel'' says that the latter 
contingency may often he avoided by appropriate treatment during the 
primary acute disease. 

The complications of acute otitis media are as follows: 

1. Severe inflammation of the accessory pneumatic spaces — the 
recessus epitympanicus, and especially the antrum and the cells. 

2. Destruction of the bony walls of the tjTupanic cavity or ex- 
posure of portions of, or of the entire, auditory ossicles with sub- 
sequent periostitis or necrosis. 

3. Extension of the inflammation to the labyrinth, 

4. Involvement of the contiguous venous blood vessels in the tempo- 
ral bone. 

5. Involvement of the brain and its membranes. 

Inflammation of the Accessory Pneumatic Spaces. — In every case of 
intense otitis media the lining of the recessus epit^nnpanicus, the 
mastoid antrum and the cells is involved. In most instances the 
process heals simultaneously with that in the mesotjnnpanum. Not 
infrequently, however, grave changes take place in the accessory 
pneumatic spaces. 

The presence of large cells and certain constitutional pecularities, 
such as diabetes, predispose to infection of the mastoid spaces. Ac- 
cording to Korner,® the infection does not always originate 'in the 
middle ear, but is often due to an "osteomyelitis petrosa," and the 
mastoid cells are secondarily involved. 

Insufficient drainage through the middle ear (through the tube) is 
the most frequent cause of inflammation of the accessory cavities. If, 
during an inflammation in' the middle ear, the pneumatic sinuses are 
invaded and the former is suddenly drained, the process subsides in 
both situations. When, however, the infection is intense in character, 
the means of communication are not sufficiently patent to establish an 
exit for the secretions. This results in one or more of the following : 

1. The connections with the tympanic cavity ulcerate, the mucous 
membrane trabeculae are destroyed, and gradually sufficient drainage 
is established so that spontaneous healing occurs. 

2. Though the process in the pneumatic spaces persists, the bac- 
terial excitants diminish in virulence and a chronic discharge of puru- 
lent exudate into the middle ear is established. 

3. The vascular communications between the antrum and the 
periosteum of the mastoid process convey the infection from the 
former to the latter, where a periostitis develops, The process in the 



1580 SURGERY OF THE HEAD 

mastoid cells goes on to the formation of minute abscesses ; the bony 
walls of the canals undergo more or less destruction, so that additional 
communications with the antrum (fistulae) are established. Occa- 
sionally, a considerable portion of the mastoid process undergoes 
sequestration. 

When periosteal suppuration is established, it may perforate ex- 
ternally (mastoid tistula). In this event, the symptoms of inflamma- 
tion subside and spontaneous healing may follow. However, this is 
the outcome only when a large cortical sequestrum is expelled and the 
spontaneous opening is a large one. In most instances, secondary' pro- 
liferation of granulation tissue, in an unsuccessful effort to eliminate 
the sequestrum, destroys more or less extensive areas of the temporal 
bone, often as far as the tegmen tympani, or extends backward, in- 
volving the posterior cranial fossa. 

Perforation of the suppurative process medially into the digastric 
fossa is not so rare as external rupture. This is accomplished through 
a large cell located at the medial side of the mastoid process (Bezold^°). 
Rupture of the abscess is likely to be followed by a deep cellulitis of 
the neck, which at first may simulate phlebitis of the jugular vein. 
However, as a rule, a suppurative cervical adenitis follows. 

The upper wall of the auditory apparatus may also be involved and 
become necrotic, and sectors of the bone may be spontaneously ex- 
pelled. As a rule, however, it is necessary to approach this region by 
surgical means and to remove the necrosed bone with gouge, chisel, 
etc. 

4, The most baneful outcome of the infection occurs when retained 
pus and granulations gain access to the dura or labyrinth. TTie 
process either perforates the tegmen tympani and gains access to the 
middle fossa of the skull, or enters the sigmoid fossa by way of the 
posterior mastoid cells. In acute otitis media the latter is most com- 
monly the case. Involvement of the labyrinth occurs frequently in 
connection with chr-onic inflammatory processes. 

5. A certain number of cases of virulent middle ear infection are 
attended with general septic infection. According to Korner,^ the 
infection gains access to the circulation through a number of small 
veins in the bones {osteophleMtic pyemia). Leutert^^ believes that 
the infection enters through the sigmoid sinus. 

KiimmeP divides mastoiditis as follows: 

1. Diffuse, suppurative inflammation of the mucous membrane 
lining the hollow spaces of the temporal lone, in which the antrum 



THE SURGERY OP THE EAR 1581 

and the larger cells are filled with purulent exudate. The process is 
usually a mild one, but is very likely to become chronic. 

2. Inflammatory infiltration of the lining of the hollow spaces of 
the temporal hone, in which the cells of the mucous membrane are 
swollen and the bone is softened and necrosed. This often occurs in 
connection with very acute infections. There is a little pus in the 
antrum and not infrequently an extradural abscess is present. In 
this form the clinical symptoms are very severe. 

3. Osteitis of the temporal hone occurs occasionally with but little 
involvement of the hollow spaces. In this form the primary lesion is 
probabl}^ in the bone. 

In most instances mastoiditis is secondary to otitis media and the 
former takes on the character of the latter. Form 1 may be so mild 
as to cause the surgeon to hesitate in regard to operative measures. 
However, the tendency to chronicity, even in this class of cases, 
should be taken into account, especially when it is remembered that 
an acute exacerbation is likely to develop at any time. 

The prognosis of mastoiditis is to a considerable extent influenced 
by the promptness with which operative efforts at relief are made. 
Early operation prevents the development of serious complications in 
most instances. Spontaneous healing is very rare. Most cases, ex- 
cept in tuberculosis and diabetes, heal in from four to six weeks fol- 
lowing the operation. 

1. The clinical manifestations of mastoiditis are moderate in form 
1, and not so severe in the others as those attendant upon the provoca- 
tive otitis media. Pain is described as boring, tearing, deeply located, 
and is often referred to the temple. Tenderness is marked, especially 
over the planum. Fever is variable and is indicative of the character 
of the infection. The general symptoms are those of an infectious 
process. 

The diagnosis of mastoiditis is not always easy, at first. When 
otitis media is attended with tenderness, its increase is significant and 
swelling is diagnostic. 

An erroneous diagnosis may be arrived at in connection with 
phlegmonous otitis externa, cellulitis of the parotid gland or of the 
neck. In doubtful cases incision is justified. A coexisting otitis media 
is of course helpful in every regard. Persistence of fever after the 
drum has ruptured is a suspicious circumstance. 

2. Ulceration and necrosis of the bony tvalls of the tympanic cavity. 



1582 felJRGERY OJ^ THE HEAD 

and ossicles are a part of the clinical picture of suppurative otitis 
media. 

3. Lahyrinthian disease occurs when infection travels through the 
fenestrae. Habermann^^ has shown that the bones of the internal ear 
may be involved in an osteomyelitic process. The affliction is charac- 
terized by a loss of the sense of balance, dizziness, vomiting and nys- 
tagmus. In these oases the doom of the function of hearing is sealed. 
In some instances the infection extends along the fibers of the acusti- 
cus or through the aqueductus cochleae into the arachnoid cavity or 
through the aqueductus vestibuli into the sacculus endolymphaticus ; 
in both instances meningitis or a serious phlebitis develops. 

4. Infections of the sinus and the hulh of the jugular vein occur as 
the result of extension of middle ear inflammation by way of the small 
vessels (phlebitis) leading from the mucosa of the mastoid cells or as 
the result of an extradural abscess which extends through the wall of 
the sinus. The other cranial sinuses may be involved by extension of 
the thrombus from the transverse sinus. The bulb may be directly 
invaded through the floor of the tj^Tupanic cavity, and the caveronous 
sinus may be infected by the same route. 

Of the infections of the cranial contents by extension from the 
middle ear, extradural abscess, especially in the sigmoid fossa, is most 
common, although suppuration above the tegmen tjTnpani also occurs. 
The process gains access to the cranium either as the result of destruc- 
tion of the bone, or by way of the lymphatic and blood vessels. In a 
certain number of cases the infection travels in the connective tissue 
surrounding the vessels leading from the antrum. Suppurative pro- 
cesses of this sort are likely to be responsible for leptomeningitis. 
Brain abscess in connection with otitis media is rare. 

The treatment of otitis media in mild cases should be directed to 
correction of the nasal and pharyngeal conditions which interfere with 
drainage af the middle ear. In tlie more severe cases it is customary 
to apply so-called antiphlogistic measures. The ice bag' often in- 
creases pain; the use of a "cooling" rubber tube coil is more satis- 
factory. The application of a leech over the mastoid process is of 
doubtful utility. Early paracentesis is the treatment of choice. The 
patient is narcotized, the drum is exposed t>y means of an ear speculum, 
and is widely incised at its anterior inferior aspect. Local anesthesia 
of the drum may be achieved in from twenty to thirty minutes by a 
soft cotton pack soaked in concentrated cocain solution or a solution 
of equal parts of phenol, menthol- and cocain. The pain of otitis media 



THE SURGERY OF THE EAR 1583 

may be controlled by the application of a 5 to 10 per cent carbo- 
glycerin solution. This is kept in contact with the drum by a light 
cotton tampon. Too frequent or prolonged use of the agent causes 
sloughing of the soft parts. After a paracentesis or spontaneous per- 
foration of the drum, the canal should be cleansed by frequent, gentle 
lavage with boroglycerin, etc. Bier's hyperemia (p. 249) is of doubt- 
ful value. Vaccine therapy is still an indefinite quantity. Delay in 
opening the mastoid cells is not permissible. If simple incision does 
not afford relief, the antrum must be opened. 

Chronic otitis media, when primarily of low grade, is secondary to 
processes of similar character in the pham^-x and in the region of 
the opening of the eustachian tube. It possesses importance in its 
influence upon hearing and has no surgical significance. Probably 
many of the cases are luetic and tuberculous in character. Many 

TIMES THE CONDITION IS A SEQUEL OF INFECTION OF THE PHARNYX AND 

MASTOID CELLS w^HiCH HAVE NOT BEEN TREATED. In somc instances the 
process shows an intermittent character (chronic recurrent otitis 
mediu) and is very likely to "flare up" into an acute intracranial or 
menacing labyrinthian complication. How^ever, most cases of chronic 
otitis media go on to sclerosis with the formation of adhesions. In 
this cla.ss of cases the discharge of pus through the perforated drum 
varies widely. The secretion often emits an offensive odor. 

The prognosis in chronic middle ear disease, from the surgeon's 
standpoint, involves the danger — only too frequent — of abscess of 
the temporal loeb, sinus phlebitis, cerebellar abscess, etc. 

The treatment is of course directed toward the relief of the under- 
lying cause. Mechanical cleansing of the tjTnpanum is imperative. 
This often calls for the exercise of considerable manipulative skill, es- 
pecially when it is necessary to remove granulomatous tissue from 
portions of the tj'mpanic cavity difficult of access. It is important 
that the latter be kept dry ; Politzer^ uses alcohol for the purpose. The 
therapy of this class of cases has become a very highly specialized art 
(see Kerrison,*^ Moos," Politzer^). 

Tuberculosis of the middle ear occurs in connection with all stages 
of pulmonary tuberculosis and is often complicated by a mixed infec- 
tion. It is characterized by rapid destruction of the auditory appa- 
ratus in the absence of the clinical picture of inflammation ; the facial 
nerve is often paralyzed early in the disease. In children under seven 
years of age, a considerable percentage of cases of mastoiditis is 
tuberculous in character. Henrica, quoted by Korner," regards most 



1584 SURGERY OF THE HEAD 

of these cases as primary bone infection — a view which Gorcke^^ con- 
tests. See also Schwabach" and Nos. 6, 7, 8 of the bibliography. 

Syphilitic pharyngitis often causes obstinate middle ear disease 
(Habarm'ann^^), ActinamycoMs of the middle ear has occmrred 
(ZaufaP«). 

New Growths of the Ear. — Granulomata occur in connection with 
all chronic (occasionally with acute) forms of otitis media. Their 
development is induced by persistent irritation of the mucosa, such aa 
that produced by foreign bodies, secretion from the middle ear, hairs, 
cotton shreds, epithelial scales, cholesterin and lime crystals, necrotic 
bone, etc. The small tumors are covered with a layer of epithelium, 
the larger with a coating of pavement or cylindrical epithelial cells. 
When they protrude into the auditory canal, they become polypous in 
form and often reach gigantic proportions and protrude from the 
meatus. Although they are likely to recur, they should be removed. 
This is best accomplished with the snare, after which the stump is 
cauterized with chromic acid or the galvanocautery. 

Genuine fibromata of the external ear are rare. Keloids occur in 
connection with perforations of the lobule for earrings. These often 
attain great size, especially in the negro race. They should be ex- 
tirpated. Recurrences after complete removal and aseptic healing 
are not common. So-called fibromata of the auditory canal are prob- 
ably granulomata into which connective" tissue had been deposited. 

Angiomata involve the external ear, especially in children, as a 
part of growths on- the cheek. They are regarded as congenital in 
origin (fissural angiomata) and appear in the telangiectatic, plexiform, 
and cavernous forms (see Angiomata, p. 1158). 

Chondromata present no regional pecularities, nor do the various 
kinds of osteomata. Almost all of the other benign and malignant 
tumors found in other portions of the body appear in the region of 
the ear and are subject tx> the same laws as regards diagnosis and 
treatment (see Tumors, p. 1141). 

Pearl tumors, which resemble dermoid cysts, possess especial in- 
terest. A certain number of observers attribute their origin to the 
presence of cheesy pus, around which layers of epithelial cells are 
deposited; others consider them to be genuine tumors (see Pause," 
Schwartze^^). The former theory is the more widely accepted. Their 
clinical significance lies in the resemblance they bear to a low grade of 
inflammatory process. 

Another form of growth, resembling cholesteatomata, consists in a 



TllK SUKGEKV OF THE EAll 1585 

collection of masses of epithelial cells in the antrum or in the re- 
cesses, which occurs in connection with chronic otitis media. The pro- 
cess bears some resemblarice to changes coincident with those de- 
scribed in connection with portions of epithelium implanted iji the 
palm of the hand (p. 1241). 

Differentiation between time pearl tumors and desquam-ative otitis 
is important on the ground that the former demand radical removal, 
together with the bone, while the latter often heals spontaneously. 
The true pearl tumor is also verj^ frequentl}^ the seat of inflammatory 
processes which extend into the skull and give rise to serious intra- 
cranial complications. 

Carcinoma and soixoma do not present any regional pecularities. 
See Charazac,^** Korner," and Nos. 6, 7, 8, and 11 of bibliography. 

The Operative Opening of the Hollow Spaces of the Mastoid Processes. 
— The mastoid cells and the antrum are opened {antrumotomu) for 
the purpose of affording egress to inflammatory products, which is 
often a life saving measure. It is not sufficient to open the mas- 
toid CELLS ALONEy THE ANTRUM MUST BE EXPOSED. This is aCCOmr 

plished vdth the chisel, gouge, and mallet. However, there is no objec- 
tion to the use of electrically driven instruments. As a matter of fact, 
the instrumentarium used is very similar to tJiat described in connec- 
tion with o.perations upon bones and joints (Part IV), except with 
regard to size. 

The skin is sectioned five to ten millimeters behind the ear, in a 
curved line down to the lip of the mastoid process; additional room 
may be obtained by carrying a second incision transversely backward 
just below the linea temporalis, through which the sinus becomes 
readily accessible. After the hollow spaces are opened, the wound 
is lightly tamponed wuth iodoform gauze. Granulations make thei.* 
appearance in a few days and healing progresses rapidly, providing 
the wound is not too firmly tamponed — a practice, perhaps, too com- 
monly indulged in by otologists. Small portions of necrosed bone are 
frequently expelled during the healing, which requires about five or 
six weeks. 

Exposure of all the air spaces of the middle ear (the so-called 
radical operation of chronic otitis media and cholesteatoma) is des- 
tined to afford relief in cases of obstinate middle ear disease which 
threatens to cause sinus complications. The exposure is made in the 
manner stated above, but is perhaps somewhat wider in extent, so as to 
make the posterior wall of the bony auditory canal accessible. The 



1586 



SURGERY OF THE HEAD 



soft parts are elevated with the elevatorium. Once the antrum is 
opened, orientation is simple and the entire medial wall of the 
tympanic cavity may be visualized. At this time the canal of the 
facial nerve must be identified and its integrity carefully preserved; 
at the same time, invasion of the horizontal semicircular canal must 
be avoided. After removing the posterior wall of the tympanic cavity, 
the drum (if present), the granulations filling the cavity, and the 
remains of the ossicles come into view. The tympanic cavit\' is 




Fig. 761. — • Exposure in Completed Radical Mastoid Operation (Dench). 



thoroughly "excavated" by means of the bone spoon ; the stapes should 
be preserved, if possible (Stacke,^° Voss^^). 

The operation is often followed by the presence of an unsightly 
opening in the bone, for the closure of which a number of plastic op- 
erations have been devised. These do not differ in principle from 
those described in connection with plastic surgery (p. 144). The 
''blood clot" operation (Blake,^^ Reik-^) has a limited field of use- 
fulness. 



THE SURGERY OF THE EAR 1587 



BIBLIOGRAPHY 

1. Joseph. Ilandh. d. Si)Oi'. Cliir. d. Ohros., etc., Wiirzburg, 1917. 

2. Keen. Anns. Surg., 1890, Jan. 

3. KOENIG. Lehrb. d. spec. Cliir., 1904, i. 

4. Goldstein. The Laryni;oscoi)e, Oct., 1908. 

5. KuMMEL, in llandb. d. ])iakt. Chir. i, Stuttgart, 1913. 

6. Kerrison. Diseases of the Ear, N. Y., 1913. 

7. Moos. Handb. d. Ohrenheilk, i. 

8. POLiTZER. Diseases of Ear, London, 1909. 

9. KoRNER. Die otitschen Erkrank., etc., Wiesbaden, 1908. 

10. Bezold. Same as No. 7. 

11. Leutert. Arch. f. Ohrenheilk, xxxix. 

12. Habermann. Arch. f. Ohrenheilk, xlii. 

13. GoRCKE. Passows Beitr-. z. anat., etc., ii. 

14. ScHWABACH. Berliner klinik. Heft. 128. 

15. Habermann. Die luet. Erkrank d. Gehororgane, Jena, 1897. 

16. Zaufal. Prager med. Woch., 1894. 

17. Panse. Des Choleastome des Ohres, Jena, 1897. 

18. Schwartze. Arch. f. Ohrenheilk, xli. 

19. Charazac. Rev. de laryngol., 1902. 

20. Stacke. Die operativ. Freileg. d. Mittelohres, Tubingen, 1897. 

21. Voss. Verb. d. Deutseh. Gesel., 1912. 

22. Blake. Toronto meet, of Brit. Med. Assoc, 1906. 

23. Reik. Jr. A. M. A., March 31st, 1906. 



PART XI . 

SURGERY OF THE FACE 



CHAPTER I 



CONGENITAL MALFORMATIONS 



Development of the Face. — The clefts occurring in connection with 
the development of the face are a key to an understanding of the 
malformations ascribable to disturbances in this connection in early 
fetal life. The normal formation of the face, as far as malformations 
are concerned, occur as follows : 

As the frontal process growing downward approaches the rudi- 
mentary first brachial arch (mandibular arch), the processus maxil- 
lares approach from both sides between the submaxillar}^ and frontal 

processes. This frontal process is 
divided by the two nasal grooves 
into a central part (processus 
nasalis medius) and two lateral 
parts (processus nasalis lateralis). 
Two lateral processes (processus 
globulares), divided by an in- 
cisure, project outward from the 
process. 

The coalescence of the processes 
and clefts may be represented 
in a simple manner, if one con- 
siders the central nasal process 
as bounded laterally by two 
Y-shaped systems of clefts (MerkeP). The lower single limb 
of the Y extends into the oral cavity between the superior maxil- 
lary process and the processus globularis, the latter being a por- 
tion of the processus nasalis medialis of the two upper limbs; the 
median passes between the middle and lateral processes toward the 
nasal fossa, and the outer between the lateral nasal process and maxil- 
lary process toward the lower circumference of the rudimentary eye. 
The cleft of the mouth extends above the lower jaw backward to its 
lateral origin. The upper lip, together with the corresponding portion 

1591 




_L»T. NAS.PROC. 
OSSICULAR PCCCtSi 

/'j/i»iLL«Rr' Process 

L0WE.ll J«W 



Fig. 762. — Face of an EiiBRYO 
Thirty to Forty Days Old. 



1592 



SURGERY OF THE FACE 



of the jaw, is formed b}- the coalescence of the middle nasal process and 
the superior maxillary process. According to Albrecht,- the processus 
nasalis lateralis is also concerned in the formation of these structures, 
as it gives rise to the outer maxillarj- process with the corresponding 
part of the lip and the lateral incisor tooth. The so-called philtrum, 
the central portion of the upper lip, originates from the central nasal 
process, while the external is concerned in the development of the ala 
nasi, and the nostril represents the remains of the nasal groove. The 
two globular processes unite with each other by means of their median 
borders. 

From the complicated system of clefts between the processes two va- 
rieties of malformations occur. Either coalescence of the borders of 
the cleft is entirely or partially deficient and a rudimentary develop- 
ment or an excessive tissue forma- 
tion is present, or the coalescence 
goes beyond the normal and 
atresia occurs. 

The causation of congenital 
malformation of this sort is not 
clear. Whatever influences there 
are must be operative in the first 
six weeks of fetal life. The influ- 
ence of heredity is very probable. 
Haymann^ claims that this is 
shown in twenty per cent of the 
cases of harelip. It is also prob- 
able that amniotic adhesions and bands have a causative influence 
(Ziegler*). See also Lannelongue,^ Trendelenburg,® v. "Winckel.'^ 

Individual Cleft Formation. — Merkel's^ schematic representation, in 
which, however, only the most important forms are s'hown, gives a 
general survey of the embryonal clefts (Fig. 763). 

Clefts of the Upper Lip. — Clefts of the upper lip may be median 
or lateral. 

The median cleft is rare. It is caused by a failure of coalescence 
of the median side of the two globular processes and corresponds to 
the split in the lip of the rabbit. The lightest grade of the deformity 
is characterized by a slight incurA^ing of the edge of the lip. However, 
the cleft often extends into the nares and is not infrequentlj'' asso- 
ciated with cleft palate (Fig. 772). See Witzel,^ Bougon et Derocque," 
Broca.^" 




Fig. 



763. — Scheme of Facial Clefts 
(after Merkel). 



CONGENITAL MALFORMATIONS 1593 

The lateral cleft (also called labium liporinum) is the usual one. 
This form of cleft may be single, double, and may be complicated by 
cleft palate in varying degrees. A single lateral cleft may present a 
very slight degree of iticoniplete incurving of the vermilit)n border of 
the lip. 

As a rule the lateral cleft appears in the form of an incomplete de 
feet located at the side of the philtrum with its apex directed toward 
the nostril, which it approaches more or less closely, so that onl}- a 
small bridge of skin separates it from the latter (Fig. 767). The de- 
fect is always edged with mucosa and is most \^idely separated at the 
line of the oral rim of the lip. In the complete lateral cleft the de- 
fect extends into the nostril, which is wider than normal and is devoid 
of a posterior edge; the ala is drawn outward and merges into the 
outer edge of the cleft. Occasionally a complete 
cleft is bridged at its center with a small sector of 
mucous membrane. 

In double harelip (Fig. 764) one cleft is usually 
complete, the other incomplete ; as a rule the 
alveolar arch is separated only on the one side. 
The philtrum, located between the clefts, is square, 
triangular, or elliptical in shape. 

Most of the cases of complete single qr double 

Pj(j_ 7g4_ Double harelip are associated with clefts of the superior 

Harelip with Prom- m<ixilla which are continuous with the clefts of 

INENT INTERMAXIL- , , , . r\ii j.-U j.\. j. J! • j. j 

LART Bone. the lips. Oi these the severest form is represented 

by a complete lip-palate defect due to failure of 
coalescence of the edges of the entire frontal process with its neighbor- 
ing tissues. 

Extension* of the labial defect into the maxilla and on into the 
palate is always attended with gr^at deformity of the external parts. 
"When the complete lip cleft (single or double) connects with a lateral 
maxillars^ fissure, the intermaxillarv^ bone is likely to be displaced to 
one side ; as the vomer is unrestrained, it grows forward, so that the 
obliquity of the intermaxillfer}^ bone protrudes far beyond the alveolar 
arch. In this way the point of the nose and the septum are also pushed 
to one side, while the wing of the nose on that side is broad and flat 
and stretched over the cleft. The protrusion of the intermaxillary 
bone is especially marked in double lip-palate cleft. In these cases 
the defect in the lip is very wide, the vermilion edge is narrow, the 
nose flat, and the septum and the philtrum are underdeveloped, or the 




1594 



SURGERY OF THE FACE 



latter is represented by only a small skin tab. The defect in the alveo- 
lar process varies in width from a small superficial fissure to a separa- 
tion of from 1 to 2 cm. in breadth, extending into the palate. The 
teeth of the intermaxillar}' segment are almost always rudimentary 
and vary in number. In some instances the philtrum and the inter- 
maxillary bone are entirely absent. See Xos. 6 and 9 of bibliography. 
Cketts of the Nose. — Clefts of the nose are rare and are the out- 
come of failure of coalescence of the head segments of fetal life. The 
median nasal cleft, dog nose of Trendelenburg*' and Witzel,^ is the 
most common form of the deformity, and is often associated with 
malformations of the brain and skull. The nose is separated into two 
symmetrical halves by a broad median 
fissure, extending downward between 
the nostrils, which are separated by the 
vomer and the septum. Farther down, 
the cleft extends as a median separa- 
tion of the upper lip and often involves 
the alveolar arch and the palate. Be- 
yond this, the eyes, the frontal pro- 
cesses of the superior maxillae, and the 
wings of the nose are widely separated ; 
the nasal bones may be absent. The 
halves of the nose appear as two carti- 
laginous tubes, the median walls of 
which are not in contact. In less severe 
cases the clefts of the palate, the lips, 
and the intermaxillary bones may be 
absent; the nose is flattened, the nasal Fig. 765.— Median Nasal Cleft 

• 1 r. T ■ o (Dog Nose), 

cartilages form the upper wmgs ot a « 

Y, and the rest of the malformation may be restricted to a shallow 
indenture in the dor.sum of the nose. Congenital nasal fistulae and 
dermoids are to be regarded as remnants of malformations of this 
class. The embryology of the malformation is somewhat complex. 
See Witzel,^ Lexer," Kredel.^- 

The lateral nasal cleft is still more infrequent ; it is easily mistaken 
for the malformation coincident with oblique facial cleft (Broca,^° 
Frangenheim,^^ Xash^*). 

Oblique Facial Clefts. — Oblique facial clefts (meloschisis) present 
great varieties. They often coexist with cerebral anomalies, in which 
event the infant (fortunately) does not sur^uve. In a general way 




CONGENITAL MALFORMATIONS 



1595 



the cleft extends from the upper lip to the eye and involves either the 
soft parts-, or the soft parts and the bones. The malformation of 
course varies widely in extent and is often double. Only those of 
minor degree are susceptible to correction by surgical efforts at relief. 
See Broca," Frangenheim,'^ Nash," Morian.^^ 

Transverse Facial Clefts. — Transverse facial clefts (macros- 
tomia) are not so rare as the oblique. They represent a failure of 
coalescence of the superior and inferior maxillary processes. The 
cleft is edged with mucosa and often extends back to the anterior 
edge of the masseter muscle ; it may be bilateral. The lesser degrees 
of the deformities are restricted to a large mouth, although even in 

these instances a band of scar tis- 
sue may reach to the ear. The 
typical fissure ends in front of the 
tragus, while others extend through 
the zygoma to the temporal region. 
Atypical clefts are caused by amni- 
otic bands and may occur over the 
superior or inferior aspects of the 
cheek (Chavane^"). 

Medlvn Clefts of the Lomter 

Lip. — Median clefts of -the lower 

lip and the inferior maxilla are not 

common. They are caused by 

faulty coalescence of the arch of 

the lower jaw and represent a 

simple median fissure or extend 

through the entire bone. The 

tongue and the floor of the mouth 

may exhibit simultaneous median clefts of varying degree (Salzer^^). 

The Operative Relief of Cleft Formations. — Operations for the relief 

of cleft of the upper lip are legion. A few, illustrating the principles 

involved, wall be discussed here. The older methods of apposing the 

refreshed edges have been abandoned in favor of the silk or silkworm 

gut suture. The apposition must be exact and tension must be avoided 

by the introduction of two or three retention sutures. A simple 

method of dealing with a slight degree of uncomplicated harelip 

(attributed to Nelaton) is show^n in Fig. 767. Wide defects may be 

treated by the meihod of Mirault,* which is variously depicted in the 

literature. Fig. 768 shows the method as the writer understands it 




Fig. 766. — Oblique and Transverse 
Facial Clefts. 



1596 



SURGERY OF THE FACE 



and is especially distinctive, as it crosses the site of the defect with 
mucosa, which is now normally placed. This, after all, is the keynote 





A B 

Fig. 767. — Nelaton's Method of Dealing with Simple Harelip. A, Incision; 

B, Suture. 

of all plastic lip operations. See also methods of Hagedorn,^^ and 
resume by Lexer. ^° 

The operative relief of double harelip, unless complicated by the 
protrusion of the intermaxillary bone, does not differ in principle 






-4^^^v.^^^a^ 




Fig. 768. — The Steps of Mirault 's Operation for Harelip. 



CONGENITAL MALFORMATIONS 



1597 



from that already described. Here again, MiraiiltV^ old method 

(Fig. 769) best meets the indications in most cases. Lexer-" in his 

presentation depicts a number of methods and also describes in detail 

his own procedure devised to obviate "inrolling" of the repaired lip. 

In cases of double harelip tvith protrusion of the maxillary hone, a 





Fig, 769. — Mirault's Method of Correcting Double Harelip. 



number of methods are emploj^ed. The older one of resecting the 
protruding bone has been abandoned. Of the various methods of 
overcoming the deformity, suh periosteal section of the vomer and 
septum (v. Bardeleben,-^ Delore-^) is the one most generally prac- 
ticed. After the mucoperiosteal covering of the lower edge of the 

vomer is incised longitudinally, it 
is freed on both sides by means of 
the periosteal elevator and the 
vomer is divided with bone cut- 
ting forceps. Light backward 
pressure replaces the intermaxil- 
lary bone and causes the two bony 
segments of the divided vomer to 
overlap (Fig. 770). The overrid- 
ing vomer is held in place by a 
catgut suture and the soft parts 
are closed over its edge. See 
Krause-Heymann.^^ Partsch-* re- 
sects a wedge of the vomer with 
an especially constructed forceps. 
Lexer,^° in his summary, states the 
methods of choice to be as follows : 
For single harelip, (1) complete and incomplete, use Mirault's^^ 
method; (2) for small incurving of vermilion border, use the method 
of Langenbeck as described by Wolff,-'' which is very similar to that 
shown in Fig. 768. For double harelip use MiraultV^ method (Fig. 
769) or, when the philtrum is small, use that of Hagedorn;''' for 




Fig. 770. — Intermaxillary Bone 
Eeplaced. 
Overlapping sectioned vomer held 
in place with a single suture. 



1598 



SURGERY OF THE FACE 



reposition of the premaxilla, use the method of v. Bardeleben-^ (Eig. 
770). 

The after treatment is important. The nostrils must be kept free 
from secretions so as to enable the child to breathe while nursing. 
The application of the protective dressing is attended with difficulties 
upon which much ingenuity has been exercised. As a matter of fact, 
healing takes place with the lea.st disturbance when the wound is 
simply kept covered with sterile zinc ointment; the child's hands are 
tied. The crust formed by the ointment and the secretions is easily 
removed. The sutures are taken 
out on the fifth day; light nar- 
cosis is advisable. 

Operative correction of the otlier 
facial clefts is not usually suc- 
cessful. What has been attained 
has been the outcome of the ap- 
plication of the general prin- 
ciples of plastic surgery. See 
Lexer. ^° Of the abnormalities in 
the areas of the fetal clefts and 
furrows, only a few possess sur- 
gical importance. These are 
cases of complete atresia of the 
eyelids, the nostrils, and the 
mouth. To these may be added 
an abnormal coalescence of the 
mouth cleft, which produces so- 
called microstomia. It is easily conceivable that all kinds of mal- 
formations are liable to occur in the fusion of the various head 
segments, which include those merely offensive from an artistic stand- 
point to those representing unsightly deformities. 

In the region of the eye, malformations cause peculiarities in the 
formation of the eyelids which at times involve the lachrymal sac 
Schanz-^). Dermoids and fistula in this region are also ascribable 
to congenital causes. 

Fistulce of the upper lip, the nose, and the loicer lip are also the 
result of faulty coalescence of the facial clefts. Occasionally, the 
transverse cheek cleft, and more frequently the ollique are the seat of 
fistulas (Trendelenburg®). 

The correction of malformations of this sort is carried out along 




Fig. 771. — Double Cleft Palate. 



CONGENITAL MALFORMATIONS 



1599 



the lines of plastic surgery in general. Fistuhii must be widely excised 
and the residual opening carei'ully sutured. 

So-called double Up, in the fonn of a thick protrusion of mucosa, 
appears mostly at the upper lip and is especially noticeable during 
laughter. The condition is readily corrected by excision. 

Cleft Palate (TJranoschisma) . — As in clefts of the face, failure of 
coalescence of the head segments in fetal life gives rise to congenital 
deformities of the roof of the mouth. In most cases these complicate 
cleft formation in the upper lip and appear as defects of the hard 
palate of varied form and extent. Their formation is explained 

in a similar manner to that of the abnormal 
facial clefts. The failure of coalescence of 
the frontal and maxillary processes is due 
to various causes, which are very similar to 
those already discussed, and, in some in- 
stances, is no doubt due to the traction 
of amniotic hands (Dursy,^^ Fernet,^^ 
Draudt2«). 

Union of the palatine plates with one 
another and the vomer may not take place 
at all, or may occur only on one side, or in 
a few areas and remain opep in the others. 
Thus, clefts may be divided into complete 
and incomplete. Complete cleft palate 
{uranoschisnm) , as far as the hard palate 
is concerned, may be single or double 
(uranoschisma unilateral or bilateral), 
while the incomplete cleft (unanocoloboma) 
may be anterior or posterior. The amount 
of separation varies with the degree of development of the palatine 
processes. 

Double cleft palate is as a rule medial at its posterior end and 
divides to either side of a protruding intermaxillary bone (Fig. 771). 
This. severe form is called "wolf jaw" and is very difficult to correct. 
According to v. Langenbeck,^° this form of the malformation is likely 
to unite with the vomer on one side (usually the right) before the 
second year of life. The intermaxillary^ may be united on one side. 

Unilateral cleft palate is the form most often seen (left side). In 
these cases the cleft is in the median line in the soft palate and is 
continued up into the left nostril through the jaw and lip (Fig. 772). 




Fig. 772. — Left Sided Hare- 
lip AND Cleft Palate. 

Marked displacement of 
intermaxillary bone. 



1600 SURGERY OF THE FACE 

If there is a double harelip present, only one of the clefts communi- 
cates with the lateral cleft palate. On the cleft side the palatine arch 
is very rudimentary, i. e., the superior maxillary is underdeveloped. 
hwomplete cleft palate (urauocoloboma) of the hard palate also 
varies in degree. At times, it is associated with single or double hare- 
lip and with a median cleft of the soft palate. The anterior defect 
represents a continuation of the cleft in the alveolar process; to this, 
occasionally, a cleft in the soft palate is also added while the greater 
part of the hard palate is closed. A posterior defect of the hard palate 
is often associated with a cleft in the soft palate. The rarest form of 
the defect is s'een when the palatine processes of the superior maxilla 
fail to unite and the horizontal plates of the palatine bones and the 
velum are fully developed. In cases of this sort the defect is located 
in the median line. 

Clefts of the soft palate may be present alone, in which instance 
they are characterized by a simple incurving of the uvula, or the 

defect extends to the posterior 
edge of the horizontal plates of 
the palatine bones. As a rule, 
however, the cleft is associated 

_ _ with a greater or lesser defect 

Fig. 773. — Cleft Palate Obturator for „ , , 

Infants (Warnekros). ot the bony palate. 

Intra-uterine healing o-f 

clefts of the palate is shown by a slight separation of the bones, which 

is covered with thin mucosa. Usuallj^, the velum is abnormally short 

and imparts a nasal character to the speech (Kiister^^). 

The disturbances consequent to cleft palate relate (1) to inter- 
ference with nursing and deglutition, and, later, with speech; and 
(2) to inflammation of the mucous memirane^. The latter is ex- 
pressed in all forms of inflammatory processes involving the naso- 
pharynx and the eustachian tube with its dire consequences to the 
auditor}' apparatus. The inability, in children, to take food and the 
overflow of milk through the nostrils is a distressing contingency — 
one which often causes the death of the infant (pneumonitis, bron- 
chitis, etc.). Temporary assistance in feeding may be acorded by the 
device of "Warnekros^^ {Y'lg. llS). In later life the disturbances of 
speech are a great affliction. See Gutzmann.^^ 

The operative measures of relief in cleft palate are based on the early 
work of V. Graefe,^* 1816, and v. Langenbeck,^^ 1861. Between these 
periods a number of surgeons devoted much effort to improving the 




CONGENITAL MALFORMATIONS 



1601 



technic of the procedure, notably Dieflfenbach,^" Fergusson,'^ Lanne- 
lougue,^ and Roux.^® The corrective procedures are called staphijlor- 
rhaphy and uranoplasty or, when both the hard and soft palate are 
defective, the term urano-staphyloplasty is used. The operation in all 
cases should be preceded by removal of hypertrophied pharj-ngeal 
tonsils. Chloroform narcosis is used by most surgeons. The flow of 
blood into the trachea is obviated by placing the patient in Rose's posi- 




FiG. 774. — Position of Head in Cleft Palate 
Operations. 

Whitehead mouth gag in position. Insert shows how 
the edges of the defect are refreshed. 



tion (Fig. 774), supplemented by the use of a suction apparatus. The 
mouth is held open with a Whitehead gag (Fig. 77-4). 
The teclinic of the procedure is divided into four acts. 

1. Refreshing the edges of the defect is accomplished by picking 
up the tip of the soft palate with a long tenaculum and, with a thin 
sharp knife, denuding the edges of the separated soft palate. The 
edges of the hard palate are trimmed off with a stiff cartilage knife. 

2. The lateral incisions through the involucnim palatum, which 
make loosening and medial displacement of the flaps possible, are car- 
ried through the mucosa and the periosteum. They begin near the 
hamulus, are carried close to the teeth, and end in front between the 



1602 SURGERY OF THE FACE 

lateral incisors. The flaps must not be too narrow in front ; in this 
way injury to the palatine arteries is avoided. Bleeding is usually 
inconsiderable. As soon as the first incision is made, it isi tamponed 
with iodoform gauze. 

3. Elevation of the mucoperiosteal flaps is the most important step 
in the operation. It is best accomplished from the lateral incisions; 
the tampon is removed and the flap raised by means of an elevator. 
When the flap is raised, the soft palate is relaxed by inserting a small 
chisel into the posterior aspect of the lateral wound (obliquely inward 
and upward) toward the hamulus, and fracturing it. The lateral 
tampons are then replaced. 

4. Exact apposition of the denuded surfaces is the final step of the 
operation. This is readily attainable by means of an appropriately 
fashioned needle holder. Silk is usually used for the purpose. The 
suturing is begun from behind. Some surgeons use silver wire and 
others use silkworm gut, which may.TDe fastened with shot. When only 
the soft palate is defective, relaxation incisions may not be necessary. 
Small defects in the bony palate are treated in the same way as the 
larger ones. In complete douhle maxillary -palatine clefts the harelip 
is corrected first and, after this is healed, the defect in the palate is 
closed. 

In the after treatment, sterile fluid nourishment is administered and 
the mouth is frequently cleansed with a mild sterile disinfectant solu- 
tion. At the end of a week, the tampons and sutures are removed. 
The sterile diet and painstaking cleanliness are maintained for another 
week. While the operation is followed by great anatomical improve- 
ment, speech is never normal. However, this may be astonishingly 
improved by systematic "speech and breathing exercises" (Gutz- 
mann^^). 

In very severe form of cleft palate, the operation described above 
does not suffice. In these cases a number of methods are employed. 
For instance, Lane^^ turns down a flap from the side of the roof of 
the mouth and sews it into the previously denuded defect ; Moskowicz*" 
uses a flap from either side of the defect and, after inverting them, 
sutures them over the defect; v. Eiselsberg*^ mobilizes the vomer and 
turns it down into the cleft. See also Lexer.^° 

When the malformation does not interfere with nutrition and delay 
is permissible, it may be advisable to massage the separated alveolar 
processes with the view of reducing the width of the cleft before 
operating. Brophy^- denudes the edges of the bony defect, forces the 



CONGENITAL MALFORMATIONS 1603 

two m^lxillac together, and holds them apposed by means of silver 
wires passed through and through the bones just above the alveolar 
processes. The wires are twisted over lead plates and are kept in 
place for three weeks. The soft palate is repaired later. 

The supplementary use of a prosthesis improves the character of 
speech very much. All of these are based on the principle of pre- 
venting air from entering the nasopharjTix. The principle was 
worked out by Siirsen/^ after whose original apparatus all subsequent 
ones are modeled. See also Schiltsky,** Warnekros,^^ Lexer.^" 

BIBLIOGRAPHY 

1. Merkel. Handb. d. topog. Anat., 1885-1890. 

2. Albrecht. Arch. f. klin. Chir. xvi. 

3. Haymann. Arch. f. klin. Chir., 1903, Ixx. 

4. ZiEGLER. AHgem. Path., 1901. 

5. Lannelongue. Arch, general de med., 1883. 

6. Trendelenburg. Deutsch. Chir., 1886, i. 

8. WiTZEL. Arch. f. klin. Chir. xxvii. 

7. v. WiNCKEL. V. Volkmann's Samml. klin. Vortr., 1904. 

9. BouGON ET Derocque. Rev. d. orthoped., 1908. 

10. Broca. Traite de Chir., Duplay et Reclus, v. 

11. Lexer. Arch. f. klin. Chir. Ixii. 

12. KredeI/. Deutsch. Zeitschr. f. Chir. vii. 

13. Frangenheim. Beitr. z. klin. Chir., 1909, Ixv. 

14. Nash. Lancet, 1898. * 

15. MORIAN. Arch, f . klin. Chir. xxxvii, with lit. 

16. Chavane. Bull, de la soc. d'anat., 1890. 

17. Salzer. Zeitseh. f. Heilk., 1902, xxiii. 

18. MiRAULT. Jr. d. chir. de Malgaigne, Paris, 1844, ii. 

19. Hagedorn. Zentrbl. f. Chir., 1892, No. 14. 

20. Lexer, in Handb. d. prakt. Chir. i, Stuttgart, 1913. 

21. V. Bardeleben. Versamm. baltisch. Arzte Rostock, 1868. 

22. Delorb. Gaz. med. d. Lyon, 1868. 

23. Krause-Heymann. Surg. Op., N. Y., 1913. 

24. Partsch. See literature of No. 20. 

25. Wolff. Arch. f. klin. Chir. xxv. 

27. DuRSY. Zur Entwicklungsgeschiehte d. Kopfes, Tiibingen, 1869. 

26. ScHANZ. DeiTftsch. med. Woch., 1898, No. 18. 

28. Fernet. Bull de la soc. anatom., 1864. 

29. Draudt. Deutsch. Zeitschr. f. Chir., 1906. 

30. V. Langenbeck. Arch. f. klin. Chir., 1861, ii and v. 

31. KiJSTER. Arch. f. kHn. Chir. xlvi. 

32. Warnekros. Verb. d. Deutsch. Odont Gesel. vii. 

33. GuTZMANN. Berlin, klin. Woch., 1895. 

34. V. Graepe. Mitteil d. med-chir. Gesell., 1816. 

35. V. Langenbeck. Arch. f. klin. Chir., 1861, ii. 

36. DiEFFENBAOH. Chir. Erfahr. u. d. Wiederherstellung Zerstorter Telle, 

Berlin, 1834. 



1604 SURGERY OF THE FACE 

37. Fergusson, Med.-Chir. Trans., London, 1843, xxviii. 

38. Roux. Mem, sur. la stapbylorrli., Paris, 1825. 

39. Lane. Lancet, 1908. 

40. MosKOWicz. Arch. f. klin. Chir., 1907. 

41. V. EiSELSBERG. Arch. f. klin. Chir. Ixiv. 

42. Bropht. Southern California Pract., 1911. 

43. SiJRSEN. Deutsch. Vierteljahi'sschr. f. Zahnheilk, Vienna, 1867- 

44. ScHiLTSKY. tjber neue weiche Obturen, etc., Berlin, 1881. 



CHAPTER II 
INJUEIES OF THE FACE 

Contusions of the face, even slight ones, are attended with consider- 
able effusion of blood, except where the skm is closely attached to the 
bone, as over the zygoma, the chin, and the bridge of the nose. 
Heniatomata of the eyelids and cheeks are particularly menacing in 
appearance. However, sloughing rarely ensues. Lacerated wounds 
are produced by blunt, tearing force; avulsion of the soft parts is 
rare, although tearing of the nostrils and mouth (by a cane, an um- 
brella, a fence picket, etc.) is not so uncommon. The application of 
great force (such as an explosion, grenade fragment, bird shot, etc.) 
is followed by extensive laceration of the soft parts and grave injury 
to the bone. 

Aside from the very extensive injuries, wounds of the face heal 
mare rapidly than those located elsewhere in the body and are com- 
paratively rarely infected. This is explained by the great vascularity 
of the face, and by the free bleeding which mechanicajly cleanses the 
wound surfaces. However, a policy of complacency in the latter 
regard is to be deprecated, for, if infection does develop, it is likely to 
be attended with grave consequences. For this reason contused and 
lacerated wounds should be carefully cleansed, and, when sutured, 
ample provision for drainage must be made. The necessity for appo- 
sition of the wound surfaces is especially urgent in injuries involv- 
ing the eyelids and the lips. The sutures must he widely separated 
from one another. The treatment of this class of cases is extensively 
discussed elsewhere (Part I, chap. iii). 

Incised wounds of the face are often complicated by involvement of 
the nasal passages and the mouth. Loss of substance by cutting 
instruments is particularly distressing in this situation (traumatic 
amputation of the nose, lips, etc.). "Wounds of this sort are very 
likelj^ to be attended with division of large vessels and nerves, includ- 
ing Stenson 's duct. As already stated, wounds of the face bleed very 
profusely, especially those involving the anterior maxillary, the super- 
ficial and the deep temporal arteries. 

1605 



1606 



SURGERY OF THE FACE 



Deep, incised wounds of the cheek and parotid region often divide 
the branches of the facial nerve with consetiuent paralysis of the 
muscles. The larger branches of the nerve are easily repaired by 
suture (see nerve suture, p. 579). "When the nerve is not primarily 
sutured, secondary' repair may be practiced. If this fails, anastomosis 
of the peripheral stump with the spinal accessory or hypoglossal nerves 
may be followed by restoration of function (Ballance and Stewart,* 
Gushing,- Frazier and Spiller,^ Korte*). However, muscular action 
is attended with so-called associated movements of the shoulder and 
tongue which mar the benefits derived from the procedure. In this 
class of cases, muscleplasty as practiced by Lexer'' gives gratifying 
results ( see also Nordmann*' ) . For 
the purpose, Lexer^ makes an in- 
cision over the anterior temporal 
region, exposing the fibers of the 
temporal muscle, from which he 
separates a goodly bundle of 
fibers (Fig. 775). After the skin 
is tunneled, the fibers are drawn 
forward by means of two silk 
ligatures and the latter knotted 
close to the eyelid. A similar flap 
is fashioned from the anterior 
edge of the masseter muscle and 
fastened in the same manner in 
the nasolabial fold (Fig. 775). 

Division of the branches of the 
trifacial is rarely followed by 

anesthesia ; the nerve usually regenerates rapidly. Adherence of a 
branch of the nerve to a scar may be the cause of neuralgia. In these 
eases a small neuroma usually develops in the scar or close to it, and 
when this is removed the pain disappears. 

Wounds of the cheek, especially those penetrating into the mouth, 
are likely to involve the duct of the parotid gland, and, occasionally, 
an external salivary fistula is 'the result. The condition is easily cor- 
rected by splitting the duct and tuniing it into the mouth through 
a stab wound in the mucosa (p. 1629). Injuries of the muscles heal 
without loss of function, except when the levator palpebrarum is sev- 
ered; in this event, ptosis develops. It is necessary to expose the 
muscle and suture it (AVeber"). 




Fig. 



775. — Muscleplasty in Facial 
Paralysis (Lexer). 



INJURIES OF THE FACE 1607 

Incised wmiuds of the face are especially responsive to careful 
repair hy suture. If bleeding is thoroughly arrested and the edges 
of the wound carefully apposed, primary union almost always follows. 
Portions of the face that are completely severed (point of the nose, 
external ear) should be carefully sutured into place; in a number of 
instances a favorable result is thus obtained (v. Bergmann*). 

GunsJiot ivounds of the face usually involve'the bone. They do not 
present a special problem, except that which is peculiar to their loca- 
tion. Suicidal wounds, when the revolver or other firearm is held in 
the closed mouth, are likely to be extensive — • the result of the explo- 
sive action of the discharge, "Wounds of this sort are important 
because of the complications, i. e., injuries of the hraiii, interference 
wnth respiration — the result of injury of the mouth and involvement 
of the large vessels. Th^ injury to the mcmth and tongue may be 
attended with severe primarv- hemorrhage from the branches of the 
lingual and internal maxillary arteries, with secondary' bleeding or 
with inflammatory'- swelling of the soft parts, either of which may 
demand immediate tracheotomy. Arrest of the bleeding may be 
attended with considerable difficulties. It is, of course, desirable that 
the divided vessels be ligated in the contiguity of the wound. It may, 
however, be necessar^^ to tie the external carotid in its coniinuity in 
order to control the bleeding. ^ 

Gunshot U'ounds of the face are more likely to he infected than are 
other classes of injuries. This is due, in part, to the fact that com- 
minution of bone is always attended with great trauma and more or 
less extensive bloody infiltration of the soft parts, and also because 
many of the wounds communicate with the m'outh, the nose, and 
accessory cavities. All of these conditions favor the occurrence of 
secondary hemorrhaged The latter is particularly disquieting, as 
attempts to ligate the bleeding points only spread the infection, and, 
therefore, it becomes necessary to tie the afferent vessel or vessels in 
their continuity (lingual, temporal, external carotid). A certain 
number of gunshot wounds of the face are followed by the develop- 
ment of traumatic aneurisms. 

Injuries of the eye by birdshot, with total destruction of the eyeball 
and lids, are not uncommon. The most severe injuries to the contents 
of the orbital cavity occur when a projectile enters it through the 
temporal region. 

Injury of the facial and trifacial nerves by projectiles do not differ 



1608 SURGERY OF THE FACE 

from those described above in connection with incised wounds of these 

t 
nerves. 

The treatment of gunshot wounds of the face, other than that just 
discussed, is treated in the general part of this work (p. 908). 

Freezing and burns of the face are especially important because of 
the distressing' deformations sequential to healing. The eyelids 
(ectropium) , the nostril^ and the mouth are especially likely to be the 
sites of cicatricial deformations. These may, to a considerable extent-, 
be avoided by the prevention of suppuration and the early employment 
of shin grafting. In this class of cases the Thiersch method (p. 20) 
is particularly useful. 

For Acute and Chronic Infections see general part. 

BIBLIOGRAPHY 

1. Ballancb and Stewart. Brit. Med. Jr., 1903. 

2. Gushing. Anns, of Surg., Phila., 1903. 

3. Frazier and Spiller. Univ. of Penn. Med. Bui., 1903. 

4. KoRTE. Deutsch. med. Woch., 1903. 

5. Lexer, in Handb. d. prakt. Ghir. i, Stuttgart, 1913. 

6. NoRDMANN. Ghir. Kong. Verb., 1912, ii. 

7. Weber, in Handb. d. Allgem. u. .spec. Ghir. von v. Pitlia u. Billroth, iii. 

8. V. Bergmann. Deutsch. Ghir., 1880, 



CHAPTER III 

PLASTIC SUKGERY OF THE FACE 

Rhinoplasty. — Eeplacement of the nose with a single layer of skin 
is always followed by shrinkage of the tlap. This was in a measure 
overcome by Dieffeiibach/ who used a double flap, i. e., one with skin 
on both sides. The introduction of artificial bridges failed. An im- 
portant step forward was taken by v. Langenbeck,^ who is responsible 
for so-called periosteal rhinoplasty, in which a flap consisting of skin 
and periosteum was taken from the forehead. Later, v. Bardeleben^ 
turned a flap of this sort down from the forehead and covered it with 
skin flaps derived from the cheeks, which he slid over the raw surface 
of the former. In 1861 Oilier* used a bone flap from the nasal process 
of the superior maxilla, which he slid under the periosteal flap of v. 
Langenbeck. This opened the way to osteoplastic repair of the nose. 

The plastic operations on the nose are employed for the relief of 
saddle nose and for complete and incomplete rhinoplasty. 

The operative relief of saddle nose is employed when the point, the 
alae and the septum are preserved. The deformity is usually the out- 
come of destruction of tissue due to lues, though it may result from 
trauma, tuberculosis and acute osteitis. The operative method of 
Koenig^ is as follows : 

A transverse incision through the deepest portion of the depression 
mobilizes the soft parts so that they can be pulled down to their 
normal position. The resulting defect, which extends into the nasal 
cavities, is covered by means of a flap from the forehead. This flap is 
a prolongation of the nasal bridge w4th its base at the root of the nose ; 
it is cut out of the forehead so that it is six to seven centimeters long 
and only one centimeter in width (Fig. 776). After the skin and 
periosteum have been incised, the cortical portion of the bone is chis- 
eled through along the cut in the periosteum. The flap of skin and 
bone thus outlined is now separated from the diploe from above 
downward by means of a flat thin chisel ; the flap is fractured at its 
pedicle, inverted and sutured into the defect. Thus the shell of bone 

1609 



1610 



SURGERY OF THE FACE 



forms the external and the skin the internal surface of the nose. The 
lower edge of the inverted flap is sutured to the mobilized lower soft 
parts so that the skin of the latter overlaps the former. The skin 
flap, which is taken from the forehead in the usual manner, is sutured 
upon the raw surface of the first flap and forms the external skin of 
the newly formed hridge of the nose (Fig. 776 B and C). 

The small "skin tab" left at the root of the nose is trimmed after 
several months. After this, a number of "adaptation operations" 






B C 

Fig. 776. — Koenig 's Saddle Xose Operation. 

A,, a, Bridge of nose flap (skin and bone) ; b, skin flap from forehead; c, defect 
formed by transverse incision. 

B, a, Bridge of nose flap turned down; b, held in place by catgut sutures. The 
skin at b remains free for union with forehead flap. 

C, a, b, Defects in forehead; c, skin flap from forehead sutured in place over 
the bridge of the nose. 

are usually necessary in order to fashion the newly made nose in 
accord with the rest of the face. 

A number of modifications of the method have been devised by' 
various surgeons. Of these, that of Israel" is worthy of consideration 
(see bibliography). Transplantation of portions of bone from the 
tibia or a rib, and the implantation of decalcified bone, are also prac- 
ticed with more or less success. 

In simple saddle nose, in which it is not necessary to apen the nasal 
cavities, a simple procedure often suffices. A transverse incision is 
made over the root of the nose down to the periosteum, the soft parts 
of the nasal bridge are elevated with a periosteal elevator, and a section 
of bone of suitable dimensions (from the tibia or a rib), together with 
its periosteum, is introduced. In this class of cases the method gives 



PLASTIC SURGERY OF THE FACE 



1611 



excellent results, provided the cavity of the nose has n-ot been entered 
during the manipulations (v. Mangoldt/ Albee^). 

In the severest farms of saddle nose, with much shrinkage of the 
Bof t parts, Lexer'* splits the nose longitudinally and uses the skin as an 
interior lining for the new nose. 

Complete rhinoplasty is necessary when the nose is entirely lost 
(carcinoma, syphilis, trauma, etc.). The available methods are desig- 
nated as the French, Indian and Italian. 

The French method (Nelaton," Serre^^) is used when the bony 
framework of the nose is preserved. The defect is closed by means of 
two lozenge shaped flaps taken from- the cheeks. Today the method 




Fig. 777. — Schimmelbusch 's Ehinoplasty Operation. 



a, Bone flap from forehead turned dovra. 

h, Defect in forehead closed by transplanted curved scalp flap. 

c, Kesult of plastic operation. 



is used only' to cover with skin an inverted osteoplastic flap taken from 
elsewhere. Of the other procedures, oidy those the fundamental prin- 
ciple of whi<^h consists iri the formation, of a flap of skin and hone 
retain practical value. Of these, the method of Koenig^ is modified 
so as to meet the indications in complete rhinoplasty (Rotter,^- Schim- 
melbusch^^). Schimmelbusch^^ forms, a flap from the forehead much 
like that described in connection with saddle nose (Fig. 777), except 
that it is made larger. The base measures from 2 to 3 cm. between 
the eyebrows and the upper end from 7 to 9 cm. close to the hair line. 
A thin plate of bone is elevated with the flap hy means of a broad, 
thin chisel. The flap is then wrapped in iodoform gauze and the 
plastic closure of the forehead carried out as shown in Fig. 777. The 
raw surfaces of the flap may now be covered with skin or, which is 



1612 



SURGERY OF THE FACE 



better, the formation of granulations may be awaited (four to eight 
weeks) and the grafting be done then. After the raw surface is 
covered with skin it is implanted into the nasal defect. The bone plate 
is sawed in the middle and angled like the roof of a house and the 
flap is twisted so that the skin is turned outward. By refreshing the 
defect the bony edge of the pyriform aperture is exposed and the 




Pig. 778. — Implantation of Flap upon the Nose. 



nasal flap, the sides of which have also been refreshed, is placed accu- 
rately upon it. If it is necessary to construct a septum, this can be 
taken from the skin edge of the pyriform aperture, after it has been 
refreshed, in the form of two thin skin flaps (Fig. 777). In three 
weeks the pedicle of the frontal flap is cut through. 

The operation is not without its technical difficulties and has certain 



PLASTIC SURGERY OF THE FACE 



1613 





Fig. 779. — -Kepair of Defect in 
Wing of Nose. 



objectionable features. Many of the latter have been overcome by- 
Lexer,'' who employs the principle of Koenig' but modifies its technic 
in a manner which gives excellent results. A description of the pro- 
cedure is too elaborate to reproduce here. See bibliography. 

The Italian mctJiod of rhinapULstij, which employs flaps from the 

arm, is rarely used at the present 
time, except when skin is utilized 
to cover a previously reconstructed 
bony defect (Fig. 778). 

Incomplete rhinoplasty is em- 
ployed for the purpose of replacing 
portions of the nose, such as one 
half of the nose, an ala, tip or 
septum. Defects of this sort are 
caused by lupus, lues, carcinoma 
and trauma. 

A defective wing of a nostril 
alone is readily closed by the use 
of a pedunculated flap taken from the contiguous nasolabial fold 
(Fig. 779). 

Cheiloplasty. — Plastic operations on the lips are destined to correct 
defects or to improve deformations. All or a part of a lip may- be 
destro3^ed as the result of noma, 
gangrene, and in the removal of 
new growths. Among the latter, 
carcirioma of the lower lip often 
demands extensive removal of 
substance. Deformation of the 
lips is frequently sequential to 
cicatrization following tuberculosis, 
lues, hums, etc. Plastic repair 
of the lip goes back to early his- 
tory. However, modern cheilo- 
plasty is based on the work of 
Dieffenbach,^ who first employed 

the entire thickness of the cheek, including the mucosa, for the purpose. 
Of the many methods more or less transiently en vogue, only those 
which include covering the new lip with mucosa are of practical value. 
In complete or incomplete replacement of the lower lip, as is fre- 
quently necessary in connection with operative removal of carcinoma 




Fig. 780. — Greater Part of Lower 
Lip Excised, Liberating Incision 
IN Cheek Down to Mucosa of 
Mouth. 



1614 



SURGERY OF THE FACE 




Fig. 781. — Plastic Formation op 
Border of Lip. 



in this situation, the correctional procedure varies with the amount of 
normal tissue it is necessary to remove. 

After removal of small, superficial new growihs, the mucosa of the 
lip may be removed by means of transverse elliptical incisions and 
subsequent suture; on the other 
hand, larger processes, which in- 
vade the skin, should be removed 
by wedge shaped excision of the 
entire thickness of the lip, and the 
point of the wedge must extend, 
well into the chin. One half of 
the lower Up may he removed in 
this way and the edge of the de- 
fect apposed by suture without 
any serious subsequent deformity. 
Still larger defects are closed by the modified Dieffenbach^ method as 
follows: An incision is made from the angle of the mouth in the 
direction of the external auditory meatus, crossing the masseter muscle 
to a finger's breadth in front of the ear. The knife divides only the 

tissues down to the mucosa of the 
mouth (Fig. 780). A rectangle of 
mucous membrane, 1 cm. high, is 
fashioned so as to retain its connec- 
tion with the lower flap of the 
cheek (Fig. 781). At the end of 
the transverse cheek incision an in- 
cision is made running obliquely 
toward the inner corner of the eye 
(Fig. 781), and the lower flap is 
mobilized from the alveolar pro- 
cesses until the mucous membrane 
edges of the defect can be brought 
together within the mouth and 
closed with buried catgut sutures. 
By drawing up these sutures the 
mucous membrane of the remnant 
of the lip and the mucous membrane of the cheek flap are approxi- 
mated. This is. followed by approximation of the old and the newly 
formed lip borders (Fig. 782). The end of the oblique incision in the 
cheek is sutured to the corner of the wound of the upper lip — and 




Fig. 782. — Completion of Suture op 
Lip; Formation op Corner op 
Mouth, 



PLASTIC SUllGEKY OF THE FACE 



1615 



after a triangular piece is excised from the redundant cheek tissue, 
this space is also sutured (Krause-IIeymann'^). 

In complete loss of the lower Up two flaps are fashioned in the 
manner indicated in Fig. 783, the mucous membrane of the cheek 
being utilized in the manner just described (v. Bruns^"'). 

As is the case with plastic repair of the nose, that of the lip is 
attainable by a number of methods too numerous to relate here. All 
of these, however, are based on the principles of the methods described 
above. See also Abbe,^" and especially Lexer." 

Stomatoplasty. — Ectr opium of the Up is corrected in the same way 
as is the similar deformity of the eyelid ; a V-shaped incision is sutured 
in the form of a Y. In severe cases the scar must be excised and the 
lip replaced by pedunculated flaps. 

In contracture of the oral orifice the mouth is enlarged by means of 
lateral incisions and the mucosa utilized in the manner described in 





Fig. 783. — Eestoration of Lower Lip (v. Bruns). 



connection with defects of the lower lip. For extensive operative 
measures in this connection see Lexer." 

Meloplasty. — The plastic repair of the cheeks is often necessary in 
connection with stomatoplasty or cheiloplasty in cases of defects of the 
cheek or in cicatricial ankylosis of the lower jaw. In the latter class 
of cases the mobility of the jaw is restored by removing the cicatricial 
tissue and replacing it with normal ; hence, the chief precaution in 

EVERY PLASTIC OPERATION UPON THE CHEEK IS THE AVOIDANCE OF 

SHRINKAGE OF THE IMPLANTED FLAP. As in Other situations, the im- 
plantation of a single layer of skin flap is followed by contraction and 
interference with function. It is, therefore, necessary to replace the 
mucosa with one layer of transplant and the skin with another 
(Gussenbauer^'^). In suitable cases, the mucous membrane contiguous 
to the defect may be slid or jumped into its buccal aspect and a similar 



1616 



SURGERY OF THE FACE 



procedure may be carried out on the face. However, this is not 
always feasible, especially when the loss of substance is great. In 
these cases it is necessary to replace the mucosa with one layer of skin 




Fig. 784. — Plastic Eepaib or Cheek. 

A, Flap carried to cheek from neck; B, folding the flap over, after dividing 
the pedicle. 

and the cheek with another in the manner shown in Fig. 784 A and B 
(IsraeP^). The pedicle of the flap is severed fourteen days after the 
primary transplantation and folded on itself as shown in Fig. 784B. 






Fig. 785. — Blepharoplasty (v. Langenbeck). 

The fold is trimmed off and sutured fourteen days later. In less 
extensive loss of substance it is often possible to fashion a mucous 
membrane flap from the floor of the mouth and the side of the tongue, 
which is used to close the defect on the inner aspect of the cheek j 



PLASTIC SURGERY OF THE FACE 



1G17 



the outer may then be closed in the usual way (Lexer"). Care must 
be taken to replace the mucous side of the defect witli skin devoid of 
hair. Stenson's duct and the facial nerve must be shown proper 
consideration. 

Plastic Replacement of Hairy Areas. — For cosmetic reasons at times 
it is advantageous to utilize flaps covered with hair for purposes of 
replacement of loss of substance. For the eyebrows and mustache 
pedunculated or free flaps may be taken from the scalp. However, 
the former are far more satisfactory, as the hair follicles of a free 
implant are exceedingly likely to undergo insular or total atrophy. 

For the eyebrow, a flap may be ad- 
vantageously taken from the hairy 
scalp of the temporal region. A 
mustache is readily formed by jump- 
ing flaps into a defect of the upper 
lip from the chin. 

Blepharoplasty. — Defects of the 
eyelids are caused by trauma, or by 
ulcerative processes in connection 
with tuberculosis, hies, necrosis fol- 
lowing erysipelas or anthrax; or it 
ma}^ be the outcome of the radical 
extirpation of nebplasms. 

In determining the technic of 
blepharoplastic measures it is im- 



l"^ portant to know whether the sl'i^ 




Fig. 



r86. — Blepharoplasty 
(DiefEenbach). 



alone or the conjunctiva also is 
destroyed. In the latter instance, 
a flap consisting of skin only is 
always followed by shrinkage of the 
implant and return of the deformity. Lexer® divides the surgical 
problem into four operative groups. 

To the first belongs the Indian method, in which an ample peduncu- 
lated flap for the upper lid is taken from the temporal region and 
for the lower lid from the cheek. Fig. 785 shows the method used in 
connection with the lower lid (v. Langenbeck^) . 

The method of sliding in a direct line (Dieffcnbach^) is based on 
the principles of plastic surgery discussed elsewhere (p. 144) ; its 
application to the eyelid is shown in Fig. 786. 

When it is necessary to construct an entire new lower lid, an 



1618 SURGERY OF THE FACE 

incision somewhat longer than the base of the defect is carried horizon- 
tally outward from the external canthus ; a second incision divides the 
tissues downward, parallel to the outer edge of the defect. A rhom- 
boid shaped flap is thus formed, which is dissected off and slid into the 
defect. Celsus^'-' liberates a flap from either side of the defect in much 
tlie same manner as is shown in connection with repair of the lower 
lip. 

The fourth method of repair consists in transplantation of a free 
flap (Wolfe-**). See Plastic Surgery, p. 14-1. 

When it is also necessary to replace the mucosa, the inner aspect of 
the flap is covered by the methods of Uhthoff-^ and Jordan." The 
former fashions a triangular flap from the mucosa of the upper lid, 
which he turns into the defect of the lower lid. At the end of the 
eighth day the flap is severed from its upper attachment and the skin 
defect is closed in the usual way. Jordan-- uses a double skin flap 
from the forehead in the same manner as is shown in Israel's method 
of meloplasty. The implantation of a free transplant of mucous mem- 
brane is of doubtful usefulness (Wolfler-^). 

BIBLIOGRAPHY 

1. DiEFFEXBACH. Die Op. Chir., Leipzig, 1845, i. 

2. v. Laxgexbeck. Deutsch. Klinik., 1859. 

3. V. Bardelebex. Lehr. d. Chir., etc. (8th ed.), iii. 

4. Ollier. See. imper. de med. de Lvon, 1863. 

5. KoEXiG. Chir. kong. Verh., 1886, No. 2. 

6. Israel. Chir. kong. Verh., 1887, No. 2. 

7. V, Maxgoldt. Chir. kong. Yerh., 1900, Ko. 2. 

8. Albee. Bone Graft Surgery, Phila., 1915. 

9. Lexer, in Handb. d. prakt. Chir. i, Stuttgart, 1913. 

10. Nelatox. Gas de trop, Paris, 1868. 

11. Serre. Traite sur I'art d. rest, les deform, de la face, Montpelier, 1842. 

12. Rotter. Chir. kong. Yerh., 1889, i. 

13. ScHiiiMELBUSCH. Chir. kong. Yerh., 1895, ii. 

14. Krause-Heymaxx". Surgical Op., N. Y., 1915. 

15. V. Bruxs. Quoted by Lexer Xo. 9. 

16. Abbe. Med. Record, April, 1898. 

17. GussEXBAUER. Prater med. Woch., 1885. 

18. Israel. Arch. f. klin. Chir., 1887, xxxvi. 

19. Celsus. Quoted bv Lexer, Chir. kont'. Yerh., 1912, i. 

20. Wolfe. Med. Times and Gaz., 1876. 

21. Uhthoff. Deutseh. med. Y'och., 1895. 

22. JoRDAX. Deutseh. med. Woch., 1895. 

23. Y^olfler. Arch. f. klin. Chir., 1888. 



CHAPTER IV 

NEUEALGTAS OF THE HEAD 

Neuralgia in general has already been discussed (p. 1032). How- 
ever, the problem in connection with the head possesses some particular 
features which are taken up at this time. Of the superficial nerves, 
the trigeminus (with the exception, perhaps, of the sciatic) is most 
often the seat of neuralgia. Whether this is due to the variety of 
functions that this nerve is concerned in or to its peculiar anatomical 
relationship is not clear. The fact that its branches traverse a num- 
ber of bony foramina may have a bearing upon this aspect of the 
solution. 

Pain, which after all is the dominant factor in trifacial neuralgia, is 
always sudden in onset and varies widely in its intensity ; however, it 
is never slight. It is described as stabbing, tearing, boring, and 
lancinating, and at times is so unbearably severe that the patient 
commits suicide. In many instances, the pain is paroxysmal and an 
attack may be induced by relatively slight influences, such as a light 
touch on the skin, a breath of cold air, muscular movements coincident 
with laughter, speech, swallowing, chewing, etc., and by psychic influ- 
ences. A paroxysm may last for only a moment. Sometimes the 
attacks occur every few minutes for daj^s. After a time, the intervals 
between attacks become shorter and shorter. Occasionally they occur 
at certain periods of the year (spring or fall). 

In the course of the disease the nerve is tender over* certain definite 
points (pain points), which usually correspond to bony foramina. 
These points are, of the first or supra-orbital division, the supra- 
orbital foramen, palpebral point in the upper eyelid, the nasal point 
at the bony side of the nose ; of the second division, the infra-orbital 
foramen, a point in the upper lip lateral to and below the wing of the 
nose, a point at the anterior portion of the temple near the malar 
bone ; and of the third division, the mental foramen, a point over 
the inferior dental foramen and the zone located immediately in front 
of the tragus. In neuralgia of the first and third division, a point of 

1619 



1620 SURGERY OF THE FACE 

tenderness is found over the parietal eminence. As this borders on 
the domain supplied by the occipital nerve, the pain point must be 
ascribed to the proper nerve. Neuralgia of the trigeminus may in- 
volve only two or all of the branches of the fifth nerve. In some 
instances, a peripheral causative factor may be restricted to the domain 
of a single division (alveolar abscess), yet the pain may radiate to the 
other branches. Irradiation of pain of this sort may extend to distant 
nerve areas, such as from the auriculotemporal to the shoulder. 
However, radiating pain is never as severe as it is in the nerve trunk 
primarily involved. 

Almost all of the attacks or exacerbations are attended with so-called 
irritation symptoms, which consist in redness of the conjunctiva, 
lacrimation, increased flow of nasal secretion and saliva, redness of 
the skin, sweating, and a feeling of heat. Herpes usually appears 
upon the forehead. Often, involvement of the facial nerve is evi- 
denced by fibrillary contraction and spasm of the muscles of the face, 
and irritation of the motor root of the fifth nerve is attended with 
spasm of the muscles of mastication. In severe cases, a condition of 
general muscular spasm develops and this is associated with nausea 
and vomiting. Occasionally the pulse is slow. 

"When trifacial neuralgia heals spontaneously, the pain disappears 
very gradually. Unfortunately, this outcome is rare. Temporary 
disappearance of the symptoms is not uncommon, but usually, even 
after removal of the seemingly causative peripheral division, the 
attacks return. Krause^ says "Of my 73 cases of peripheral resec- 
tion of a division of the fifth nerve, only one seventh remained free 
from relapses ; relief rarely lasted more than two years. ' ' 

The prognosis of trigeminal neuralgia, strange to say, does not 
usually involve danger of a fatal outcome. As a rule the afflicted is 
well nourished, except in cases in which partaking of food precipitates 
an attack of pain. The outcome is largely dependent upon the cause 
of the neuralgia. If this is removable, recovery often follows. Opera- 
tive measures of relief render the outlook better. They must not be 
delayed too long. 

The general causation of trifacial neuralgia includes infectious dis- 
eases, malaria, influenza, typhus, typhoid and .smallpox; systemic 
poisoning with mercury, lead, alcohol and nicotin ; diabetes mellitus, 
gout and anemia. Of the chronic infectious diseases, lues must always 
be taken into account. No doubt luetic narrowing of the foramina of 
exit is often responsible for the disease. 



NEURALGIAS OF THE HEAD 1621 

Determination as to rEKii'iiEKAL or central seat of the cause of 
THE neuralgia IS VERY IMPORTANT. Ill the event of a peripheral lesion, 
such as scars, foreign bodies, tumors, etc., which, according to clinical 
experience, is capable of producing neuralgia, one is justified in 
regarding this as a competent cause and in acting accordingly. If 
the affliction immediately follows exposure to cold or an injury of a 
definite area of the face and the symptoms are restricted to this zone, 
a causative association may be assumed. In each instance it must be 
remembered that an initial nerve lesion progresses toward the center. 
It does not require the exercise of imagination to realize that the 
larger the number of branches of the nerve involved, the higher up 
(more centrally) one must look for the causative lesion. In this con- 
nection, irradiation sjTnptoms must be excluded. When the three 
branches of the nerve are involved, it is justifiable to assume that the 
lesion is intracranial, such as periosteal and osteal changes in the 
middle fossa of the skull. In instances in which neuralgia is limited 
to a single branch (as is usual at first), this does not by any means 
indicate that the lesion is peripheral (unless the latter is demonstrable) , 
and it may simply herald the influence of a beginning central cause. 
The motor root of the nerve is the last to give evidence of impairment. 
In not a few instances, pressure on the sensory fibers of the fifth nerve 
is attended, not with neuralgia, but wdth anesthesia. Strange to say, 
an association between cerebral lesions and netlralgia is very rare. 
However, occasionally, when every effort at relief has failed, autopsy 
shows that a brain lesion has been the cause of the pain and that this 
has not been attended with any other sjTnptoms. 

The general treatment of trifacial neuralgia must encompass the 
removal of all possible causes, of which the following deserve especial 
attention: pathological teeth, ears and eyes, the cavities of the face, 
and sclerosis of the alveolar processes. Foreign bodies located near, 
or within, a nerv'e trunk must be sought for. The medicinal treatment 
should not be omitted. Of the host of remedies used, quinine and 
strychnia have been of actual service. Morphin and cocain are only 
palliative; their protracted employment always leads to an unfortu- 
nate condition of affairs. Electrotherapy has relieved the pain. 

The injection of alcohol (80 per cent) into the foramen rotundum 
(second branch) and the foramen ovale (third branch), first used by 
Schlosser^ and extensively practiced by Harris^ and Offerhaus,* 
affords relief for varying periods of time. The success of the technic 
is entirely dependent upon the operator's knowledge of anatomy. 



1622 



SURGERY OF THE FACE 




Fig. 787. — Trunk of Supraorbital 
Nerve Twisted Out; Peripheral 
Portion of Nerve " Coming 
Awat. ' ' 



Peripheral operations are Likely to accomplish the purpose if exe- 
cuted before the asceudiiig changes involve additional branches of the 
aerve. Simple division of the affected nerve (neurotomy) is no longer 
practiced and has been replaced by extirpation of as large a segment 
of the nerve trunk as is possible {neurectomy) or, as the present 
procedure is called, nerve extrac- 
tion (Thiersch"). The nerve is ex- 
posed and, without being sectioned, 
is grasped (transversely) with an 
especiall}' constructed forceps, by 
means of which it is slowly twisted 
on its axis. In this way the peri- 
pheral branches and the central 
trunk are extirpated to an astonish- 
ing extent ; in some instances a 
portion of the gasserian ganglion 
has been avulsed. 

The first trigeminal iranch (ophthalmic) is exposed by a curved 
incision 3.5 cm. in length, carried along the superior edge of the orbit, 
exposing the supra-orbital ner^^e as it emerges from its foramen or lies 
in the incisura (Fig. 787). 

The second trigeminal hrancli 
(maxillary nerve) is attacked as 
follows : 

The incision begins i/o cm. below 
the inner edge of the lower margin 
of the orbit, runs obliquely out- 
ward and downward to the posterior 
lower edge of the malar bone, and 
is about 4 cm. in length. The 
upper branches of the infra-orbital 
nerve soon come into view at the 
superior edge of the wound. These 
are left undisturbed in their con- 
nection with the trunk, while the 
peripheral branches are pulled out 
with forceps. The infra-orbital foramen is now exposed 1 cm. below 
the inferior edge of the orbit, a little internal to its middle, and 
the periosteum is pulled down until the branches of the infra-orbital 
nerve are clearly visible. Next, the periosteum and floor of the orbit 




Fig. 788. — Twisting Out the Peri- 
pheral Branches of the Infra- 
orbital Nervs. 



NEURALGIAS OF THE HEAD 



1623 



are stripped backward as far as possible. Then, with a broad re- 
tractor, the orbital contents and periosteum are carefully lifted, 
exposing the nerve — a white stripe visible through the translucent 
upper wall of the canal farther back, l^'ing free in the sulcus. The 
canal is opened by removing a wedge shaped section of bone with a 
narrow, straight chisel. The entire contents of the canal is lifted out 
of the bony channel on a blunt hook, as far back as the orbital fissure. 
However, the artery need not be isolated from the nerve unless this is 
readily accomplished. The forceps are introduced as far back as 
possible into the orbit and the nerve drawn out with a slow, constant 
pull. The peripheral nerves are rolled up on the clamp by a very 

slow, twisting motion 
until the finest terminal 
branches are delivered 
from the cheek, the upper 
lip, and the ala of the 
nose (Fig. 788). 

The branches of the 
third, or inferior maxil- 
lary, division may be re- 
moved separately. 

The lingual nerve is 
extirpated by exposing it 
as it enters the base of the 
tongue, i. e., between the 
ramus of the lower jaw 
and the palato-glottidean 
fold. It lies in the neigh- 
borhood of the last three 
molar teeth, just under the mucous membrane, exactly at the point of 
transition from the side of the tongue to the floor of the mouth. With 
the mouth held widely open and the tongue drawn forward and 
upward, the mucous membrane is incised at the point stated (Fig. 
789). The nerve is immediately visible and is grasped with forceps 
and twisted out. 

The auriculotemporal nerve is easily reached through a small vertical 
incision at the upper angle of the parotid gland. The nerve is accom- 
panied by the superficial temporal artery, from which it is readily 
separated ; it is then grasped with forceps and twisted out. 

The superior maxillary nerve may be exposed at its exit through the 




Fig. 789. — Extraction of the Lingual Nerve. 



1624 



SURGERY OF THE FACE 



foramen rotundum only by osteoplastic resection of the zygoma and 
dissection into the sphenomaxillary fossa. The skin incision begins a 
finger's breadth outside and below the end of the eyebrow, descends 
along the posterior edge of the frontal process of the malar bone and 
thence, in a flat arc (concavity upward), backward and downward to 
the lower edge of the zygoma and along this to the anterior edge of 
the articular tubercle. Here the incision turns obliquely upward, end- 
ing just above the zygoma in front of the ear. The zygoma is now 
exposed along its medial surface with the elevator, and, close to the 
articular tubercle, is divided with bone forceps. "When the skin is 
retracted downward, the branches of the facial nerve are placed out 
of danger and the zygoma may be divided. The anterior origin of the 
zygoma is now sectioned and the bone thus liberated is turned down 
(Fig. 790). The approach to the sphenomaxillary fossa is now free; 
only the anterior fibers of the temporal muscle need be divided. Pro- 
ceeding into the depths 
with small sponges and a 
blunt elevator, the surgeon 
advances along the pos- 
terior surface of the su- 
perior maxilla to reach the 
sphenomaxillary fossa. The 
fat and the plexus of veins 
are pushed aside, and the 
internal maxillary artery is 
carefully freed and pulled 
backward with a retractor. 
The inferior orbital fissure 
is located with a probe and 
any fat which interferes 
with the view is carefully 
removed. The nerve now 

comes into view where it emerges from the foramen rotundum and 
runs obliquely forward and outward through the inferior orbital 
fissure; here it is hooked up (Fig. 790) with a small tenaculum, 
separated by blunt dissection, and lifted away from the infra-orbital 
artery. It is now grasped with the forceps and cut close to the 
foramen. The wound is drained and the zygoma sutured back into 
place (Liicke,** Braun,''' v. Friedlander*). 




Fig, 



ZYCOMfl. 



790. — Extraction op the Superior 
Maxillary Nerve, 



The zygoma is turned down and the temporal 
muscle retracted. The nerve is lifted with a 
blunt hook. 



NEURALGIAS OF THE HEAD 



1625 



Tlio third branch uf the trigeminus may be reached at tlie foramen 
ovale as follows : 

The incision of approach is very similar to that employed in attack- 
ing the second division. The zyg-oma, together with the parotide- 
masseteric fascia and masseter muscles, is turned down, exposing the 
coronoid process of the lower jaw. This is freed from muscle with 
an elevator and cut off at its base with bone cutting forceps, exactly 
on a line with the deepest portion of the sigmoid notch. The loosened 
process, together with the attached temporal tendon, is turned up, 
exposing the infratemporal fossa and at the same time the external 
pterygoid muscle and the internal maxillary artery, which runs be- 
tween the two points of origin of the muscle. The pterygoid muscle is 
pulled upward and divided and the internal maxillary artery is cut 
between two ligatures. The external plate of the pterygoid process 
is cleared w'itli a raspatory to the point where its root joins the base 
of the skull at the foramen ovale. The large nerve trimk is seen com- 
ing out of the foramen ,• it is 
seized with the nerve forceps 
(Fig. 791) and torn out of 
the cranium. The otic 
ganglion may be removed at 
the same time. The wound 
is drained and the zygoma 
replaced and stitched into 
place (Kocher,^ Kronlein,^° 
and Krause^^). 

Intracranial removal of 
the ganglion of Gasser is a 
measure of considerable 
magnitude. Its indications 
are taken up at the begin- 
ning of the chapter. Of the 
various methods, that of 
Krause^^ will be described 
here. For additional methods the reader is referred to the bibli- 
ography (Rose,^^ Dollinger,^^ Gushing,^* Lexer^^). The technic is 
divided into three acts. 

The first act consists in opening the cranial cavity. The incision in 
the scalp begins immediately above the zygoma close in front of the 
tragus, runs convexly backward and upward, forms a half circle, and 




Fig. 791. — The Inferior Maxillary Nerve 
Lifted on a Director and Seized with a 
Nerve Clamp Just Below the Foramen 
Ovale. 



1626 



SURGERY OF THE FACE 



curves downward, back to the anterior aspect of the zygoma. The 
flap thus outlined measures at its base 3.5 cm., is 6 cm. in height and 
is about 5 cm. at its widest portion (Fig. 792). The entire operation 
is extraduraii. The periosteum is slightly pushed back from the bone ; 
a single hole is made in the cranium with a Doyen burr (Fig. 338), 
and the bone sectioned in the line of the scalp incision with the Dahl- 
gren craniotome (Fig. 753) or a de Martel osteotome (Fig. 755). 
The base of the osteoplastic flap thus formed is forcibly broken with 
any appropriate lever, exposing the dura. The line of fracture is 
usually located about 1 cm. above the zygoma. The lower edge of this 
is removed down to the base of the skull with rongeur forceps. This 
is imperative. The flap now hangs down upon the face and is out of 
the way. Krause^^ regards 
temporary^ resection of the 
zygoma as unnecessary. 

The second act — ligature 
of the middle meningeal 
artery — is now undertaken. 
The finger or a raspatorium 
separates the dura from 
the base of the skull. If a 
protruding eminentia capi- 
tata is in the way, it is 
chiseled off. The foramen 
spinosum and the artery 
traversing it soon come 
into view. The brain is 
held upward by an assist- 
ant with a broad spatula 
and the vessel, carefully 
isolated from its embed- 
ding dural processes, is 
grasped with two narrow 
bladed artery forceps and 
cut between them and tied. 

If this does not succeed, the foramen may be plugged Math gauze and 
the operation may proceed. 

The third act — exposure of the ganglion and its removal — is ac- 
complished as follows: The dura is progressively elevated (inward) 
by means of gauze pledgets held in artery forceps, until the third, and 




Fig. 792. — Extirpation of the Gasserian 
Ganglion. 

The second and third divisions exposed. The 
middle meningeal artery is tied. 



NEURALGIAS OF THE HEAD 1627 

then, considerably farther on, the second, division is exposed from the 
ganglion to the foramen rotundum and ovale. A little more manipu- 
lation, supplemented perhaps hy snipping of dural adhesions, brings 
into view the entire ganglion. If difficulty is experienced, the third 
branch is grasped with forceps and pulled outward, thus making the 
ganglion more accessible. The first branch, because of its close rela- 
tionship with the cavernous sinus, is exposed only as a part of the 
ganglion. The ganglion is now grasped at its posterior (central) 
aspect with the nerve forceps and the second and third divisions care- 
fully divided at their respective foramina of exit. By slowly rotating 
the forceps, the ganglion, together with a goodly section of the first 
division, is readily "torn out." The stumps of the second and third 
branches are pushed into the foramina. The brain is allowed to fall 
into place, a drain is inserted and the flap sutured as usual. The 
drain is removed on the fourth day. The trophic disturbances which 
occasionally occur in the eyeball are obviated by keeping the eyeball 
covered during convalescence. Of 85 cases operated upon by Krause,^ 
ten died as the result of the operation. 

BIBLIOGRAPHY 

1. Krause, in Handb. d. prakt. Chir. i, Stuttgart, 1913. 

2. ScHLOSSER. 24 Kong. f. innere Med. Wiesbaden, 1907. 

3. Harris. Lancet, 1909. 

4. Opferhaus. Arch. f. klin. Chir., 1910, xcii. 

5. Thiersch. Verh. d. Deutsch. Gesell. f. Chir., 1889, xviii. 

6. LiJCKE. Deutsch. Zeitschr. f. Chir. iv. 

7. Braun. Zentrbl. f. Chir., 1882. 

8. v, Friedlander. Deutsch. Zeitschr. f. Chir., 1898, xlviii. 

9. Kocher. Chir. Operationslehre (4th ed.), 1901. 

10. Kronlein. v. Bruns' Beitr. z. klin. Chir. xiv. 

11. Krause. Surgical Operations, i, N. Y., 1915. 

12. Rose. The Surgical Treatment of the Fifth Nerve, London, 1892. 

13. Bollinger. Zentrble f. Chir., 1900, No. 44. 

14. CusHiNG. Jr. A. M. A., April, 1900. 

15. Lexer. Verh. d. Deutsch. Gesell. f. Chir., 1905. 



CHAPTER V 

SUEGERY OF THE SALIVARY GLANDS 

Injuries of the Salivary Glands. — Of the injuries of the saJivary 
glands, only those of the parotid are of special importance. Trauma 
to the others, aside from complicating infection, even though followed 
by the formation of a fistula, causes no disturbances, as the vicarious 
opening always communicates with the mouth. 

Severe injuries of the parotid (stab and gunshot w^ounds) are likelj'' 
to be attended with involvement of the facial nerves and trauma to 
important vessels. The latter is associated with much bleeding. In 
cases of this sort, an external salivary fistula often forms at the end 
of a few days. However, most of these heal spontaneously. Primary 
union in the wound is the best prophylactic measure as regards the 
occurrence of a fistula. During repair, mastication must be avoided ; 
the patient subsists on fluid diet. 

Injuries of the parotid duct are more troublesome. As a rule the 
duct is divided by a cutting instrument, but it may be contused and 
subsequently may slough. The diagnosis is made by introducing an 
irritating substance into the mouth and noting the discharge of saliva 
from the wound. 

The treatment, in own-penetrating wounds in which the duct is 
divided, consists in its careful repair by suture. In penetrating 
wounds only the superficial wound is closed ; the duct then establishes 
a fistulous opening within the mouth. 

Salivary fistulae (parotid fistulae) after injury or pathological 
destruction of the parotid gland substance are common. Here again, 
however, spontaneous healing is not rare. The fistulous opening may 
present at any portion of the surface of the gland. The orifice of a 
fistula of this sort is usually surrounded by an area of eczema due to 
the irritation of the discharge. 

The treatment is primarily directed toward causing inflammatory 
obliteration of the opening. This may often be accomplished by the 
application to the fistulous tract every four or five days of the silver 

1628 



SURGERY OF THE SALIVARY GLANDS 



1629 



stick, or, better still, by a single aj)pIicatioii of the actual cautery. If 
these measures fail, the tract is excised and the wound closed with a 
plastic flap. In obstinate cases a portion of the gland may be 
extirpated. 

Salivary duct fistulae (fistulae of the parotid duct) cause much 
more disturbance than those of the gland and rarely heal without 
operative help. A fistula of this sort may be regarded as permanent 
(1) when the huccal mucosa is adherent to the skin; (2) when the 
peripheral end of the duct is obliterated; (3) when large defects are 
present in the duct. 

The treatment of perihanent fistulae depends upon their seat, i. e., 
huccal, masseteric, or glandular. In 1895 Delarue^ 
tabulated twent^'-six methods of treating the afflic- 
tion. Relief may be afforded by (1) reestahlishment 
of the normal path of secretion; (2) converting an 
external fistula into an internal one; (3) destroying 
the secretory function of the gland. 

Reestahlishment of the normal path of the secre- 
tion is a delicate operation. It means dissection of 
the duct and its repair by suture (Nicoladoni^). 
Converting the outer fistula into an internal one is 
the method of choice. It is desirable to implant the 
peripheral ends of the cehtral portion of the duct 
into a slit in the mucosa. As this is not often feasible. 

Fig. 793. Opera- the single or douhle perforation of the mucosa is 

TioN FOR Sali- employed. 

TULA (Deguise), Single puncture (Desault^) consists in perforating 

the mucosa at the site of the fistula with a trocar or 

or with the galvanocautery. The canal thus formed is kept patent by 

the introduction of a drainage tube until the internal flow of saliva is 

assured (8 to 10 days). 

Douhle puncture of the buccal mucosa is very simple (Deguise*) and 
is much practiced. One half of the diameter of the buccal side of the 
fistula is transfixed ("in and out," i/o cm. apart) by a cannula through 
which a silver wire is introduced. The latter is twisted (Fig. 793) 
and gradually cuts its way out. The outer wound usually heals spon- 
taneously, though there is no objection to refreshing and suturing it. 

Direct impla7itation of the central end of the duct into the mucosa 
of the mouth is accomplished by dissecting out its central portion and 




1630 SURGERY OF THE FACE 

sewing it into a stab wound in the buccal mucosa. The method suc- 
ceeds when enough of the duct is left to carry out the technic. 

The abolition of the secretion of the gland is based on experimental 
work (Langemak^), showing that ligature of the duct causes the gland 
to cease functioning. In man the measure is followed by a grave 
reaction in the gland, including sloughing and infection (see also 
Rousseau*^). 

Foreign Bodies and Calculi. — Foreign iodies gain access to the ducts 
of the salivary glands from the mouth, or from without. Of the ducts, 
that of the submaxillary gland is most often visited by a foreign body, 
usually a fish bone, a hair, a bristle, a feather, etc. 

The accident is attended with rather stormy symptoms, especially 
when the unwelcome visitor becomes coated with lime salts. The gland 
swells (i^itermittently) and is exceedingly painful. After a time the 
clinical picture of inflammation develops and this often ends in abscess 
and subsequent fistula formation. 

The diagnosis is certain only when the foreign body is palpable. 
The value of the Rontgenogram depends upon the character of the 
obstructing agent. 

The treatment should of course be directed toward removal of the 
offending substance. This may be accomplished by incising the duct. 
In some cases opening of an abscess liberates the body. If a submaxil- 
lary fistula persists, the gland may be extirpated in toto — not a 
difficult procedure. 

Salivary stmie (sialolithiasis) is rare; it attacks the ducts more 
often than the glands. The calculus consists of an organic nucleus 
and an inorganic deposit arranged in layers. Del Fabbro'^ and Kroiss^ 
have shown that the calculi are developed as the result of inflammatory 
processes in the glands (not the reverse, as has been believed). The 
pathological process alters the character of the salivary secretion, and 
the inorganic salts are deposited upon a bacterial nucleus (Klebs,^ 
Galippe"). 

The clinical picture of sialolithiasis varies. The concretions may 
lie quiescent for years and then suddenly obstruct the duct. Inter- 
mittent salivary tumor is characteristic. The swelling is very painful 
{coliques salivaires of the French) and usually develops during mas- 
tication. Occasionally, a sudden discharge of saliva and pus into the 
mouth heralds the end of an attack. Not a few cases develop an acute 
inflammatory process in the gland and this often terminates in abscess 
formation. When the stone (or stones) is located in the gland, the 



SURGERY OF THE SALIVARY GLANDS 1631 

latter picture develops primarily. In this event, the process must be 
(liagnosticatod from alveolar periostitis, not always an easy task. 

In the treatment an effort should be made to remove the stone 
through the mouth. The exceptions to this rule are when a fistula 
leads to the concretion ; when the stone lies in an external abscess ; 
and when the stone is intraglandular. Removal through an incision in 
the mouth is readily accomplished. When, however, the concretion 
is deeply Jocaicd in the suhlingual gland, removal may be difficult. 
A subsequent intrabuccal fistula is unimportant. Stones located in 
the substance of the suhniaxiUar}) or parotid gland cannot be removed 
through the mouth, but must be enucleated from without by careful 
dissection. Total extirpation of the submaxillary gland is not objec- 
tionable. However, this is not justifiable as far as the parotid is 
concerned. 

Acute Inflammatory Processes of the Salivary Glands. — Acute inflam- 
matory processes of the salivary glands are divided into primary and 
secondary. 

Of the acute primary inflammations, mumps {parotiditis epidemica) 
is the most frequent. Its discussion belongs to medicine. However, 
the occasional development of abscess in the gland, which demands 
incision, justifies brief allusion to it. More important perhaps is the- 
not uncommon complicating orchitis which also at times goes on to 
abscess formation and demands drainage; »r, if sloughing occurs, the 
testicle may have to be enucleated. 

Acute secondary inflamyyiation of the salivary glands is more likely 
to be of surgical interest. It occurs in connection with local or con- 
stitutional processes. Of the local causes, foreign bodies and stones 
(see above) and extension from contigu&us infectious processes (sup- 
purative lymphadenitis) and various forms of stomatitis (especially 
mercurial) and trauma are the most important. 

Parotitis frequently occurs as a part of a general infectious disease, 
such as typhoid fever, scarlatina, pneumonitis, influenza, variola, etc. 
It is most frequently seen in association with typhoid fever. Powers^^ 
reports a case due to the gonococcus. 

The cause of secondary inflammation of the salivary glands is 
ascribed to infections of the mouth which lessen the flow of saliva and 
thus favor invasion of the gland tissue. Pawlow^^ has shown that the 
flow of saliva is diminished after all abdominal operations. That nar- 
cosis is not responsible for the process is shown by the fact that it 
develops after operations performed under spinal anesthesia. The 



1632 SURGERY OF THE FACE 

notion that parotitis is most frequently a part of a baeteriemia has 
recently gained ground (see v. Mikulicz and KiimmeP^). It is certain 
that postoperative parotitis does not often occur when the mouth is 
thoroughly cleansed before the operation (Haubold^*). 

In describing the clinical picture only the inflammatory processes 
occurring in connection with infectious diseases and after operations 
are taken into account ; the other forms are taken up with foreign 
bodies and calculi. The beginning of the disease closely resembles 
an acute infectious disease. It usually develops early in the 
course of a systemic infection and as a postoperative complication 
makes its appearance from the third to the fifth day, rarely as late as 
the tenth. When the parotid is affected, the gland swells, is very 
painful and becomes tense. The swelling often extends from the tem- 
poral region to the neck. The appearance of the patient (especially 
when both parotids are involved) is very characteristic. The skin is 
red, edematous and immovable. Deglutition, mastication and respira- 
tion are painful. The symptoms continue to increase for three or four 
daj^s, when either resolution occurs or an abscess develops. The den- 
sity of the embedding connective tissue does not permit of diagnostic 
fluctuation. Abscess formation is likely to be multiple and is often 
attended with necrosis of considerable areas of gland tissue. Exten- 
sion of the process in the form of pyemia or proliferation into the 
visceral cavities, including the cranial cavity, is not rarely responsible 
for a fatal outcome. The connection of the posterior aspect of the 
parotid with the esophageal and retropharyngeal spaces and the medi- 
astinum favors extension of the process. This is also true with regard 
to the jugular vein, the lateral sinus, and the middle ear. 

Infection of the suh maxillary and sublingual glands is rare. In 
neither instance does the picture vary from that described in connec- 
tion with the parotid gland, except perhaps with regard to the inten- 
sity of the process and its complications. 

The treatment; is primarily prophylactic. In all infectious diseases 
and as a part of preparatory and postoperative care, the mouth is 
carefully cleansed. When the inflamipiation of the salivary gland is 
established, Bier's hyperemia (p. 249) may be employed. This is 
advantageously supplemented by the application of iodin. Progressive 
inflammation justifies immediate unburdening of the gland with the 
knife (see treatment of inflammation, p. 241). In attacking the 
parotid gland, only the skin and the fascia are divided ; the paren- 
ehvma of the gland is invaded with blunt forceps. The incision must 



SURGERY OF THE SALIVARY GLANDS 1633 

avoid the facial nerve. Counteropenings should be made. The suh- 
maxillary and sublingual glands may be widely opened. 

Chronic injlanimatory processes most often develop as a sequel to 
acute forms of the disease; ultimately suppuration occurs and this is 
drained as stated above. Recurrent attacks justify removal of the 
submaxillary and sublingual glands. In the parotid, resection of 
portions of the gland is as far as the surgeon is justified in going. 

Actinomycosis — Tuberculosis — Lues. — Antinomy cosis of the sali- 
vary glands was described by Miiller^" in 1903. It is usually second- 
ary to actinomycotic infection of the soft parts and the bones of the 
face. Clinically, it appears in the form of a chronic inflammatory 
process. 

Tuberculosis of the salivarj^ glands occurs despite the long existing 
belief that these organs are exempt from the disease. Kiittner^® has 
collected twenty-seven cases. Wood^^ thinks that the infection enters 
through the tonsil. See also Legueu et Marieu/^ Parent/** de Paoli/° 
Homuth,2i 

The process is attended with circumscribed enlargement of the 
affected gland. These areas are very likely to break down and form 
fistulae. A clinical diagnosis is impracticable and reliance must be 
placed upon the microscope. 

The treatment consists in operative removal of the process. 

Lues of the salivary glands is not as rare as tuberculosis; most of 
the lesions in twenty cases collected by Kiittner^^ were in the parotid. 

The clinical picture is one of chronic inflammation with hyperplasia 
of connective tissue. "When this is present, together with other luetic 
manifestation.s, diagnostic therapy is justified. See also Fournier," 
Claus.-^ 

Salivary Cysts. — Retention of salivary secretion occurs in connection 
with inflammatory processes, the presence of foreign bodies, and cal- 
culi in the ducts, or as the result of obstruction of the latter bj- scar 
tissue, etc. 

Cystic enlargement of the ducts occurs in the submaxillary and 
parotid glands. The condition is ascribed to acquired cicatricial or 
congenital obstruction. The affected duct is usually symmetrically 
dilated and as a rule the gland itself is more or less enlarged. The 
superimposed skin and mucosa is quite normal in appearance. Occa- 
sionally, a cystic enlargement of this sort is lined with a layer of lime 
salts. 



1634 



SURGERY OF THE FACE 



Pressure on a cyst of this sort^ when the duct is not entirely occluded, 
causes it to empty into the mouth. When the duct is closed, irritation 
of the mucosa provokes a flow of saliva only from the opposite side. 
Strange to say, the dilated duct does not reach great size ; probably 
the gland ultimately ceases to function. In other cases, an abscess 
forms and a salivary fistula develops. When an opening occurs in the 
mucosa it makes no differ- 
ence ; an opening in the skin, 
however, is followed by the 
clinical picture described 
above. 

The treatmeyit aims at the 
establishment of a vicarious 
opening into the mouth, 
which is best accomplished 
by the D e g u i s e method 
(p. 1629). 

Cysts of the salivary 
glands are due to obstruc- 
tion of one or more of the 
subdivisions of the main 
secretory duct and are 
classed with the retention 
cysts. The obstruction is 
usually due to an inflamma- 
tory process. Cysts of this 
sort are not common. No 
doubt so-called ranula be- 
longs to this class. 

Retention cysts of the 
parotid and submaxillary 

glands (for sublingual see ranula) are small (size of a hen's egg) and 
usually solitary, although multilocular cysts of the parotid are reported 
(Kroiss®). Cysts of this sort grow slowly. The diagnosis is made 
with the aspirator. The treatment consists in extirpation of the cyst. 

Echinococcus cysts of the salivary fistula are very rare (v. Mikulicz 
and KiimmeP^). 

Tumors of the Salivary Glands. — New growths of the salivary glands 
possess eonsiderable surgical importance. It is not impossible that 
most of these are of endothelial origin. On the other hand, all of the 




Fig. 794.- 



Retention Cyst of Submaxillary 
Gland. 



SURGERY OF THE SALIVARY GLANDS 



1635 



tumors discussed in Part W are found in these organs and present 
a clinical picture, the character of which is especially influenced by 
the location of the lesion. 

Hemangioiiiaia grow very rapidl}^ and demand early and prompt 
excision. Injections of alcohol, etc., never accomplish the purpose. 
Lymphangiornata are rare (Lannelongue et Achard"). 

Liponiata, fibromata, myxoinata and sarcomata do not differ from 
those of the other organs. 

Mixed tumors are the most frequent growths found in the salivary 

glands; the parotid is most often 
affected. A considerable number 
of tumors of this sort has involved 
the accessory parotid. 

Clinically, mixed tumors of the 
salivary glands appear primarily 
as a circumscribed growth, but 
soon involve the entire gland 
structure. Their motility under 
the skin is characteristic. The 
disturbances tumors of this sort 
produce relate to pressure and 
interference with mastication, 
speech," deglutition, and respira- 
tion. In a certain number of 
cases the tumor becomes malig- 
nant in character (Wilms^^). 

The treatment, as one can never 

be certain of the exact character 

of the growth, consists in removal 

of the entire gland. When the tumor is located in the parotid, this 

may be modified with the view of saving the facial nerve. 

Carcinomata occur less frequently than mixed tumors. Both the 
scirrhous and true medullary carcinomata develop in this situation. 
The scirrhous form grows slowly and runs a clinical course similar to 
that of like growths of the mammary gland. The facial nerve is 
involved early. The overh^ing skin is soon involved and in many 
instances presents a condition of infiltration which the French call 
"squirrhe en plaque" (Michaux^®). The Ijnnphatic glands are in- 
volved late. The true medullary form is richly cellular, grows rapidly 
(Fig. 795), and soon perforates the skin. This is followed by the 




Fig. 795. 



Medullary Carcinoji.\ of 
Parotid Gland. 



1636 SURGERY OF THE FACE 

events discussed in connection with carcinomata in general (Part VI, 
chap. xvii). 

Malignant tumors of the salivary glands must be diagnosticated from 
inflammatory processes, especially granulomata, tuberculosis, and lues. 
A very malignant form of sarcoma, which rapidly invades the skin, 
presents a clinical picture not unlike that of carcinoma. 

The ireatmcnt consists in total extirpation of the affected gland. 

Total Extirpation of the Parotid and the Submaxillary Glands. — 
Extirpation of the parotid is a difficult operation. In malignant dis- 
ease extracapsular enucleation is employed; the intracapsular method 
is permissible for the removal of benign processes. In the former 
class of cases the facial nerve must be sacrificed ; in the latter it may 
be preserved. 

The skin is sectioned vertically close to the tragus, from the level of 
the external ear to 4 or 5 cm. below the angle of the jaw ; this is sup- 
plemented by a horizontal incision a finger 's breadth below the zygoma, 
which extends forward about two and one half inches. The flaps are 
dissected back and the surface of the gland is exposed. Extirpation 
of the gland is begun at its lower pole, where the lymphatic glands are 
found and removed ; here the large veins are tied and the gland tissue 
is lifted from the external carotid artery. The latter is divided be- 
tween two ligatures. The gland is next separated at its anterior 
border from the masseter muscle. Removal of the posterior portion 
of the gland is not easy ; it is slowly and carefully accomplished, each 
divided vessel being at once ligated. By careful dissection the gland 
is separated from its surroundings until it is held b}' its attachment 
only to the pharynx and styloid process, from which it is finally dis- 
sociated with great care. The vessels divided during the operation are 
the external jugular, the anterior and posterior facial veins, the trans- 
verse facial, the posterior auricular, the occipital, the superficial 
temporal, the anterior articular, the zygomatico-orbital, the internal 
maxillary, and the external carotid arteries. The facial nerve is 
sacrificed. ^ 

Enucleatio7i of the sulmaxillary gland is not difficult. A curved 
incision (concavitj^ upward) is made immediatel}' below the lower edge 
of the jaw (from the symphysis to the angle) . The platysma is divided, 
the gland is lifted from its bed, the facial artery and vein are divided 
between ligatures, the attachments of the gland to the jaw are cut, and 
the liberated organ is delivered. The labial branch of the facial nerve 
is usually cut. Care must be taken not to injure the contents of the 



SURGERY OF THE SALIVARY GLANDS 1637 

digastric triangle. The deep cervical glands sliould be removed when 
the operation is performed for malignant disease. 



BIBLIOGRAPHY 

1. Delarue. These de Paris, 1895. 

2. NicoLAuoNi. Verh. d. Deutscli. Gesell. f. Chir., 25th Kong., 1896. 

3. Desault. See No. 7. 

4. Deguise. See No. 7. 

5. Langemak. Virchow's Arch, elxxv. 

6. Rousseau. These de Paris, 1909. 

7. Del Fabbro. Gaz. degli ospedali e delle cliniei., 1904. 

8. Kroiss. v. Bruns' Beitr., 1905, xlvii. 

9. Klebs. Arch. f. exper. Path. v-vi. 

10. Galippe. Jr. des Conn, med., 1894 

11. Powers. Quoted by No. 26. 

12. Pawlow. Quoted by No. 26. 

13. V. Mikulicz and Kummp:l. Die krankh. d. Mundes, 1912. 

14. Haubold. Prep, and After Treat, in Op. Cases, N. Y., 1911. 

15. MtJLLER. Orth. Festchr., 1903. 

16. KuTTNER, in handb. d. prakt. Chir. i, Stuttg^art, 1913. 

17. Wood. Univer. Penn. med. Bull., 1903, No. 10. 

18. Legueu et Marieu. Semaine med., 1895. 

19. Parext. These de Paris, 1898. 

20. DE Paoli. Tuljerc. d. ghiandoli salivari, Perugia, 1904. 

21. HOMUTH. V. Bruns' Beitr., 1911, Ixxiv. 

22. FouRNiER. Anns, dermat. et syph. vii. 

23. Claus. Berlin, klin. Woeh., 1907, No. 31, 

24. Lannelongue et Achard. Traite de cystes., etc., Paris, 1886. 

25. Wilms. Die Misehaeschwiilste, 1902. 

26. MiCHAUX. These de Paris, 1884. 



CHAPTER VI 

DISEASES OF THE TEETH AND OF THE GUMS 

While the affections of the teeth and gums have become specialized 
under the head of dentistry, there are certain aspects of the problem 
with which the surgeon should be familiar. 

Caries of the Teeth. — Caries of the teeth is the most widely distrib- 
uted disease of civilized man. Its underhdng causation is undoubtedly 
attributable to the refinements of the art of cookery. The mastication 
of firm substances, first on one side of the mouth, and then on the 
other, is the most certain prophylactic measure in this connection. 
Incidentally, this also reduces the bacterial flora of the mouth. 

The additional predisposing causative factors are as follows: 

Ahnormally close proximity of the teeth, favoring retention of 
foreign substances ; pregnancy and lactation; systemic diseases, such 
as diabetes, chlorosis, and the general infections, and heredity. 

The exciting cause of caries consists in bacterial invasion of the 
tooth and its simultaneous softening. The latter is the outcome of the 
fermentation of retained carbohydrates produced by the bacteria. 

When the carious process has destroyed the cortex of the tooth, 
exposing the dentine, the disease progresses rapidly and cavities are 
formed which ultimately extend to the tooth pulp. 

Caries may he prevented hy mechanical cleansing of the teeth, the 
avoidance of easily decomposed food, and, most of all, the proper 
physiological use of the teeth in mastication. 

Pulpitis occurs when a carious cavity extends into the medulla of 
the tooth. As the tooth pulp is richly supplied with nerve endings, an 
inflammatory process in this situation is exceedingly painful. The 
treatment consists in cleansing the cavity, removing the detritus and 
pulp (if necessarjO, and filling the carious cavity. Chronic pulpitis 
often demands extraction of the affected tooth. 

Periodontitis and alveolar periostitis is the next step after pulpitis, 
the infection extending to the tooth socket. In accord with the port 
of infection, periodontitis is divided into marginal or apical, both of 

1638 



DISEASES OF THE TEETH AND OF THE GUMS 1639 



whii'li may be acute or chronic. The treatment consists in drainage 
of the iiilV'cted area. If the process is extensive, the offending tooth 
must be extracted. The general belief that a tooth should not be 
extracted during an acute process is a relic of the dark ages. 

The extraction of a tooth is a minor operation that the surgeon is 
frequently called upon to perform. It should be remembered, how- 
ever, that the unnecessary sacrifice of a tooth should be avoided, and 
that the need for it must be great before extraction is justified. The 

tcchnic of the measure is divided 
into five acts: (1) cleansing the 
surroundings of the doomed 
tooth; (2) application of the 
forceps; (3) luxation movements ; 
(4) extraction; (5) after treat- 
ment of the wound. Cleansing is 
best accomplished with alcohol. 
In applying the forceps care 
must be taken not to grasp the 
gum nor include the alveolar 
process. The luxation move- 
ments consist in lateral displace- 
ment of the tooth which is thus 
loosened 'and is readily lifted, 
not fivistcd, out of its socket. 
The after treatment consists in 
cleaning the cavity with 3 per 
cent carbolic acid solution, which 
is followed by the application 
of iodoform powder. If bleeding 
is excessive, the cavity is tam- 
poned with iodoform gauze sat- 
urated with adrenalin solution 
(1:1000) or with thromboplastin (see Hemophilia, p. 1063). 

Diseases of the Gums. — Diseases of the gums, other than the processes 
occurring in connection with lesions of the mouth, are due to extension 
of infection from the teeth (caries). The most common of these, and 
the one properly alluded to here, is known as alveolar pyorrhea. 

Alveolar pyorrhea simultaneously attacks the alveolar processes, the 
covering of the roots of the teeth, and the gums. It is attributed to a 
lessened resistance to bacterial invasion on the part of the tissues 




Fig. 796. — Diagram of Alveolar Ab- 
scess, Eesulting from Disease of 
Molar Tooth (after the American 
System of Dentistry). 

A, Abscess arising from escape of 
septic material from B, the pulp cham- 
ber, through the foramen at apex of the 
fang; it has burrowed directly through 
the alveolar process and burst through 
the gum; C, similar abscess, Avhich has 
tracked Aovra. between the tooth and 
the alveolus, and spread out beneath 
the alveolar periosteum at D, constitut- 
ing the typical alveolar abscess; E, 
cheek ; F, antrum ; G, nasal cavity. 



1640 SURGERY OF THE FACE 

involved. The disease is characterized by a loosening of the gums 
from the teeth and the alveolar processes. As a rule, the neck of the 
tooth is surrounded by a ring of lime deposit (tartar). Pressure on 
the gum expels a few drops of pus. The root of the tooth is usually 
covered by a layer of granulation tissue, the outcome of a low grade 
of infection. After a time, the alveolar processes are absorbed or 
destroyed, the teeth are loosened and ultimately fall out. 

The treatment of alveolar pj'orrhea is directed toward combating the 
local infection and improving the patient's general condition. The 
former is essentially the work of the dentist. However, it is not out 
of place to state here that there is nothing more effective in this 

CONNECTION THAN FREE EXPOSURE OF THE INFECTED AREAS AND THE 
LIBERAIi USE OF THE THERMOCAUTERY. 



CHAPTER VII 

TUMORS OF THE JAWS 

It is of practical value to divide tumors of the jaws into those etio- 
logically connected with the development of the teeth and those inde- 
pendent of this origin. Those of the latter class are similar to those 
a])pearing in other portions of the body. 

Odontogenous Maxillary Tumors. — Follicular dental cysts appear in 
early life. They develop in the interior of the maxillae and, as they 
slowly enlarge, destroy the embedding bone until the latter is only a 
thin shell. These cysts possess a smooth wall lined with fibrous tissue 
covered with a laj^er of epithelium, and contain a clear fluid. The 
lesion is believed to represent the cystic degeneration of a tooth bud. 
The tumor is usually covered with a perfectly smooth mucosa, which is 
more or less elevated in a globular form. The diagnosis is possible 
only with the help of the Rontgenogram or the aspirator. Excision 
of the anterior wall of the cyst is followed by its spontaneous oblitera- 
tion. ^ 

AdamaxtinoMxVta (multilocular cystomata and benign central 
epitheliomata of the maxillae). — Multilocular cystomata, like maxil- 
lary cysts, originate in tooth buds. The cysts are found distributed 
throughout the entire bone and usually communicate with each other ; 
the superimposed skin and mucosa is normal in appearance. On the 
other hand, the bone is gradually converted into a thin shell, and, in 
places, disappears entirely, so that the cyst wall lies in contact with 
the mucosa and the skin. Their structure is very like that of a 
follicular cyst. 

The solid adamantinomata are encapsulated within a thin bony wall. 
The histology of these tumors is taken up in Part VI. 

Clinically, both the cystic and solid adamantinomata present the 
picture of benign growths. The diagnosis, in the cystic form, is based 
on the presence of a fluctuating tumor and the Rontgenographic find- 
ings ; the solid form can be differentiated from sarcoma only by means 
of microscopical examination of an excised portion of the growth. 

Enucleat%07i of the growth is usually followed by return of the 

1641 



1642 



SURGERY OP THE FACE 



process and this can be prevented with certainty only by excision of 
the invaded jaw (Delsaux^). 

Odoxtomata. — The terni "odontomata" is applied to tumors which 
spring from fully developed teeth. They owe their origin to changes 
in the dental anlage of one or more teeth. Tumors of this sort usually' 
appear in the lower jaw; they are encapsulated and rarely grow 
larger than a hen's egg. They consist of cement and dentin, usually 
superimposed upon an unerupted tooth. According to Malassez 
(quoted by Galippe-), the process is due to changes coincident with 
the retention of a tooth or teeth (see also Cousins^). The tumor is 
easily removed after chiseling away the superimposed shell of bone. 

Epulis : Epulis Fibromata and Epulis Sarcomata. — The term ' ' epulis" 
is properly applied only to 
tumors of the gums of fibrous 
and sarcomatous nature which, 
despite their histological differ- 
ences, present an almost uni- 
form clinical picture. 

Epulis originates from the 
periosteum of the alveolar pro- 
cesses and is attached by either 
a narrow or a broad base. It is 
located on both sides of the 
affected maxilla or on both 
maxillae (opposite one another). 
The tumor is the same color as the 
gum, or perhaps slighth' darker. 
Its consistency varies, though most of the tumors are soft. Hardness 
argues for a fibromatous, and softness, for a sarcomatous, growth 
(especiall}' giant cell) . The teeth in the area of the growth are usually 
loose. As a rule tumors of this sort grow slowly; occasionally, a 
sarcomatous lesion extends rapidl}^ (Speese*). 

In most instances, epulis exhibits the characteristics of a henign 
tumor; it does not form metastases, nor does it return when removed. 

Removal of the growth at its base is followed by return. The peri- 
osteum or periodontium from which the lesion originated must also be 
extirpated. Resection of the alveolar process is desirable. 

Fibromata, osteomata, chmidromata and angiomata do not differ 
from those found elsewhere in the body (see Tumors, Part VI). 

Sarcoma. — Sarcoma is more likely to involve the upper than the 




Fig. 



^^ 



797. — MULTILOCULAE, CYSTOMA 

OF Jaw. 



TUMORS OF THE JAWS 



16-43 



lower jaw and occurs in women ot'tener than in men. It is essentially 
a disease of early life. Its traumatic origin is extremely doubtful. 
The difl'erence between peripheral and central sarcoma is especially 
marked in tumors of the lower jaw. In the former the jaw bone is 
embedded in the growth, in the latter, the bone embeds the tumor. 
The prognosis depends upon the histology of the process. Sarcomata 
of the jaws do not display a marked tendency to metastasize. Of the 
fonns of sarcoma, the melanotic is the most malignant, round cell 
slightly less so, and the giant cell the least. 

The clinical manifestations of periosteal sarcoma are those of an 
extending growth upon the surface of the bone ; the tumor is not 
covered with bone. In central sarcoma the growth enlarges the bone 

itself, at first in the form of a circumscribed 
swelling, especially toward the periphery and 
the gums. In the beginning it is covered with 
a shell of bone tissue, but this is soon per- 
forated. Before this happens, "parchment 
crackling" may be elicited. As the process 
goes on, the bone is more or less extensively 
destroyed and the soft parts are invaded. The 
advance of the lesion is attended with symp- 
toms of pressure on the various nerves. 
Tumors located in the upper jaw occlude first 
the contiguous nostril, then encroach upon the 
orbit, and last protrude toward the face. 

The diagnosis is only certain when based 
upon the histological findings. 
The treatment consists in resection of the affected jaw. This gen- 
eral rule may be varied with respect to sarcomata limited to the 
alveolar processes, in which event these may be removed (Fairbanks,^ 
Hewson*' ) . 

Carcinoma. — Carcinoma of the jaws develops from the epithelium 
of the gums and the mucosa of the alveolar processes and the palate. 
It appears in the form of a papillomatous groivth or an iilcer with 
hard edges. Histologically, carcinomata in this situation are of the 
flat epithelial type. The central type of carcinoma originates in the 
mucosa of the maxillary antrum. Of course, in all their aspects the 
growths extending from contiguous tissue (secondary) attack the jaws. 
Carcinoma of the alveoli usually appears at the edge of the gum in 
the form of a hard, crater-like ulcer which soon invades the bone, and 




Fig. 798.— Epulis. 



1644 



SURGERY OF THE FACE 



the teeth fall out. In the upper jaw the process soon perforates the 
antrum. In the lower jaw spontaneous fracture occurs early. Pain 
is not an obtrusive symptom. 

Central carcinoma causes severe pain at the outset. Presently the 
mucosa becomes edematous. and soon the growth makes its appearance 
externally. The subsequent sequence of events is similar to that 
described in connection with sarcoma. As the carcinomatous 
infiltrate progresses, the 
osseous structure is de- 
stro3-ed until finally the 
inevitable picture de- 
scribed in the general 
part of this work (Part 
VI) closes the scene. 

Only the most radi- 
cal OPERATIVE MEASURES 
OF RELIEF ARE TO BE CON- 
SIDERED. These consist 
in TOTAL RESECTION OF 
THE INFERIOR OR THE 
SUPERIOR MAXILLA. In 

the latter instance the 
floor of the orbit should 
be preserved (Hotch- 
kiss/ Koenig,^ Morestin,'' 
Tarumianz"). 

Hyperostoses. — Hyper- 
ostoses resembling 
tumors are not infre- 
quently found involving 
the jaw bones, especially 
the upper. No doubt, 
some of these cases rep- 
resent the initial stage of leontiasis ossea (p. 1072). The lesions are of 
surgical importance in the sense that they make pressure upon the 
soft parts, which seriously interferes with function (FraenkeP^). 

Tuberculosis of the Jaws. — Tuberculosis of the jaws is either the 
outcome of extension from contiguous parts or is primary (hemato- 
genous) in origin. The former usually arises in connection with tuber- 
culosis of the alveolar processes, which has its origin in infection of 




Fig. 799. — Sarcoma of the Upper Jaw 
(Johnson). 



TUMORS OF THE JAWS 



1645 



ihe gums. The process soon ulcerates and presents the characteristic 
grayish red nodules upon its excavated surface; sequestration of the 
alveolar processes is common. As a rule, the submaxillary lymph 
nodes are swollen. In a certain number of cases, tubercle bacilli may 
be found in the exudate. The prognosis depends upon the degree of 
coexisting pulmonary tuberculosis, with which the process is so fre- 
quently associated. In any event, the indication as to treatment is 
clear. The process is radically excised and the operative area is 

treated with iodoform paste. 
Occasionally, the infection takes 
its origin from a carious tooth 
and a subsequent tuberculous 
pulpitis (MicheP-). 

A special form of tuberculosis 
appears as a granulomatous 
process originating in the mu- 
cosa of the maxillary antrum. 
In this class of cases, the lesion 
does not break down, but grad- 
ually distends the antrum in a 
manner closely resembling sar- 
coma. In the few reported cases, 
resection of the affected superior 
maxilla was followed by recovery 
(Perrier^^). 
Differentiation between carcinoma of the alveolar processes, tuber- 
culosis, actinomycosis, and lues is not always an easy task ; it requires 
the assistance of the microscope and the serological findings. 

Actinomycosis of the Jaws. — Actinomycosis of the jaws usually 
begins in the mucosa of the mouth. It is divided into a peripheral 
and a central form. In the former the jaw is invaded by extension 
from the mouth. The central form begins as a central caries or a 
central new growth and is usually located in the lower jaw. No doubt, 
the infection gjiins access to the bone through carious teeth. After a 
time, the infection extends to the cortex of the bone, which it perforates 
and thence invades the surrounding soft parts. 

The diagnosis can be made with certainty only when the microscope 
detects the ray fungus (p. 404). In central_ actinomj^cosis, sarcoma 
will often be suspected (Gaudier"). 

The treatment consists in removal of the affected part. Resection 




Fig. 



800. — Carcinoma op the Roof of 
THK Mouth. 



.1646 SURGERY OF THE FACE 

of the jaws need not be resorted to. However, the diagnosis must be 
verified before the extent of the operation is decided upon. 

Syphilis of the Jaws. — Lues of the jaws, aside from primary infection 
of the mouth, appears in its tertiary form. T'he lesion usually takes on 
the form of circumscribed or diffuse osteitis and periostitis. 

Circumscribed gummata appear most frequently in the hard palate. 
Primarily the lesion involves the mucosa of the roof of the mouth and 
extends to the bone. Here it causes a restricted area of swelling, which 
soon breaks down, ulcerates, discharges a few small sequestra, and 
perforates into the nares. In the lower jaw the infection is charac- 
terized by the formation of small nodules in the bone. 

The diffuse form of gummatoiis osteitis develops at the alveolar 
processes in the form of a more or less painful swelling of the gums, 
which soon ulcerates and suppurates and is attended with necrosis of 
greater or lesser areas of the maxillae (see syphilis, p. 424). 

The diagnosis is based on the presence of associated luetic lesions, 
the Wassermann reaction, and the primarily nodular character of the 
process. 

The treatment of lues of the jaw.s, aside from constitutional medica- 
tion, consists in extirpation of the local lesion. 

For suppurative osteomyelitis see page 290. 

For phosphorus necrosis see page 307. 

Total Resection of the Superior Maxilla. — The mortality following 
resection of the jaw, the result of lung complications (aspiration pneu- 
monitis), has led to the employment of local anesthesia in this class of 
eases with the view of leaving the "protective reflex activity of the 
larynx" unimpaired. Thus the patient expels the blood which flows 
into the air passages. The operative field is made insensihle by abolish- 
ing the conductivity of the sensory nerves distributed to it. Five c.cm. 
of a 1 per cent novocain-adrenalin solution is used for the purpose in 
the following manner : The needle of the syringe is entered immedi- 
ately below the angle of the malar bone and is advanced through the 
masseter muscle along the surface of the tuberosity of the maxilla 
a distance of from 5 to 6 cm., where it enters the pterygopalatine fossa. 
Contact with the nerve is indicated by the patient, who experiences a 
momentary sharp pain. The injection is then made and, as the needle 
is slowly withdrawn, a second 5 c.cm. is injected. This is followed by 
the abolishment of the sensory conductivity of the first division of the 
fifth nerve. The needle is entered just above the external angle of 
the eye and is carried along the bone to a depth of 4i/^ to 5 cm., 



TUMOKS OP THE JAWS 



1647 



imcision Thru 



rsONTAL VROCtSS 
iCtTIONtC 



INFRftORBlfAL 
NtRVE. 



where it reaches the superior orbital fissure and is arrested at the 
opposite side of the orbital wall. At this point 5 c.cm. of the solution 
is injected. A third, medial injection is made by entering the needle 
a finger's breadth above the inner angle of the eye and pushing it 
onward close to the bone, a distance of 4V2 to 5 cm., where 5 c.cm. of 
the solution is injected; this is distributed over the medial wall of 
the orbit. In addition to this, the operative field, including the soft 
palate, is infiltrated with the same solution. When successfully carried 
out, the method is followed by complete anesthesia. The operative 
area is also rendered anemic (see Krause-Heymann,^'"' Braun^**). 

When operating in full narcosis, the patient is placed in the Tren- 
delenburg posture and the trachea occluded with the tampon tracheo- 
tomy tube, or peroral 
intratracheal n a r - 
cosis is employed. 
Preliminary ligature 
of the external caro- 
tid artery is desir- 
able. 

The so-called Dief- 
fenbach-Weber inci- 
sion (Fig. 801), 
which avoids the 
facial nerve and 
Stenson 's duct, is 
most frequently em- 
ployed. After the 
soft parts are re- 
flected outward, the 
masseter muscle is detached from the z3'gomatic arch, the ala nasi is 
pushed inward, and the orbital septum dissociated from the edge of the 
orbit. The contents of the orbital cavity are lifted up with a retractor. 
The following 6o^((y coi?))ecf/o?is are divided : (1) the connection between 
the superior maxilla and the malar bone; (2) the connection between 
the frontal process and nasal bone; (3) the connection of the alveolar 
process and the hard palate with those of the opposite side; (4) the 
connection between the hard palate and the pterygoid process of the 
sphenoid bone. All of this is readily accomplished with the chisel. 
The operation is now transferred to the mouth. The internal incisor 
tooth is extracted; the mucoperiosteal covering of the hard palate is 




Fig. 



801. — Dieffknbach-Weber Exposure op Upper 
Jaw: Lines of Bone Sections. 



1648 



SURGERY OF THE FACE 



sectioned in the median line, and the soft palate is cut close to the 
latter. The hard palate and the alveolar process are cut (with the 
chisel), also in the median line, and last the chisel cuts the connection 
between the maxilla and the pterygoid process of the sphenoid bone. 
The maxilla is grasped with a lion jaw forceps and twisted out. Tem- 
porary tamponade of the cavity effectually controls the bleeding. 

For excision of hoth maxillae a similar technic is employed, the 
incision meeting in the median line of the upper lip. The nose is 
separated from the pyriform aperture and, after the cartilaginous 
septum is divided, is turned upward. Aside from the bone sections 
described above, the perpendicular plate of the sphenoid and the vomer 
are divided. An effort should be made to bring together the mucosa, 
with the view to shut off the nasal from the oral cavity. For modifi- 




l,IN£ OFSCCTION Of 
FtOOR or MOUTM 



TurooH «TTrtCH£P TO JftW 

Fig. 802. — Resection of the Lower Jaw in its Contintjitt. 



cations of the technic in this class of cases, see Krause-Heymann.^^ 
After the operation the patient is sat up in bed and the wound area is 
kept clean. Sterile nourishment is administered by means of a soft 
rubber catheter. 

Most surgeons use a provisional prosthesis prepared from a model 
taken hefore the operation. This is introduced at once and makes 
the subsequent employment of permanent apparatus much easier. 
The object of the prosthesis is to enable the patient to speak and to 
masticate. It is astonishing what modern dentistry has accomplished 
in this connection. 

Resection and Exarticulation of the Lower Jaw. — Resection of the 
lower jaw^, without preser^'ation of its continuity, is divided into : 

1. Resection of the bone with solution of its continuity. 

2. Exarticulation of one half of the jaw. 



TUMORS OP THE JAWS 



1649 



IhrtRlOR 
DtNTflU Nt*Vt 



3, Total resection of the lower jaw. 

Temporary resection of the lower jaw to afford access to the mouth 
is taken up elsewhere (p. 1679). 

Resection of the lower jaw involves danger of aspiration pneumo- 
nitis and is followed by grave functional disturbances and serious 
cosmetic defects. 

Resection of the lower jaw in its continuity begins with extraction 
of the teeth on either side of the doomed segment. The incision ex- 
tends along the lower border of the chin or, which is simpler, the lip 
is split at its middle; this incision is carried to the center of the hyoid 
bone and the soft parts dissected back to the desired extent. The 
bone is divided with the Gigli saw and separated from its muscular 
attaclunents (digastric, mylohyoid, geniohyoglossus and geniohyoid) 
and the buccal mucosa. The tongue is kept from dropping backward 

by means of a silk 
suture. The bone is 
now removed and a 
previously prepared 
prosthesis or bone 
graft (Albee^^) is 
placed in the gap. 
The mucosa of the 
mouth is sutured to 
that of the lip. Fig. 
802 represents the 
conditions in removal of a portion of the body of the lower jaw. 
Exarticulation of half the lower jaw is accomplished through a con- 
cave incision beginning at the center of the chin, skirting the hyoid 
bone, and ending at the mastoid process. The external carotid may be 
tied through this same approach. The flap thus formed is lifted up- 
ward, an incisor tooth is extracted at the point of contemplated bone 
section, the mucosa of the mouth is loosened from the bone, and the 
latter is cut with the Gigli saw. The anterior edge of the dissociated 
bone is grasped with lion jaw forceps and the jaw forcibly dislocated 
outward, putting the soft parts on a stretch at their inner aspect (my- 
lohyoid, geniohyoid muscles, submaxillary gland and the internal ptery- 
goid muscle) and dividing them close to the ramus. The jaw is still 
farther luxated and the tendon of the temporal muscle is divided at its 
insertion into the coronoid process. Disarticulation from the glenoid 
cavity is accomplished b}^ forcible avulsion, 



LINCUALNtRVC 



Fig. 803. 




juanKIILLARY GL.ANP 

Exarticulation of One Half of 
Lower Jaw. 



1650 SURGERY OF THE FACE 

The problem of obviating deformity involves: 

1. Secondary prosthesis. 

2. Immediate prosthesis followed by secondary prosthesis. 

3. Implantation of prostheses at the operation (ivory pegs, etc.). 

4. EmplojTiient of a bone transplant from the patient. 

Of these, the last is most desirable ; the others belong to the highly 
specialized departments of dentistry (see Perthes^^ and his bibliog- 
raphy). 

For fractures and dislocations of the lower jaw see Part IV. 

BIBLIOGRAPHY 

1. Delsaux, Jr. med. de Bruxelles, 1908, viii. 

2. Galippe. Les debris epithel. paradent. d'apres les traveux d. L. Malas- 

sez, Paris, 1910. 

3. Cousins. Brit. Med. Jr., 1908. 

4. Speese. Anns. Surg-., 1910, Hi. 

5. Fairbanks. Brit. Med. Jr., 1907. 
,6. Hewson. Anns. Surg., 1909, xlii. 
7\ HoTCHKiss. Anns. Surg-., 1910, Hi. 

8. KOENIG. Verb. d. Deutsch. Gesell. f. Chir., 1910. 

9. MORESTIN. Bull. soc. Chir., 1908, xxxiv. 

10. Tarumianz. Sarcoma und Kareinoma d. Kiefer, Berlin, 1910. 

11. Fraenkel. Berlin, klin. Woch., 1906. 

12. Michel. Korres]:)ond. f. Zahnarzte, 1909. 

13. Perrier. Med. Klinik., 1907. 

14. Gaudier. Bull. soc. Chir., No. 33. 

15. Krause-Heymann. Surg. Ops. i, N. Y., 1915, 

16. Braun. Deutsch. Zeitschr. f. Chir. iii. 

17. Albee. Bone Graft Surgery, Phila., 1915. 

18. Perthes, in Handb. d. prakt. Chir, i, Stuttgart, 1913. 



CHAPTER VIII 

THE SUKGERY OF THE NOSE AND ITS ACCESSORY SINUSES 

Satisfactory examination of the nasal cavity is only possible when 
strong light is used. The rays of light must illuminate the objective 
on the same level as the vision of the examiner. This is readily accom- 
plished by means of the light condenser and perforated head mirror so 
familiar even to the laity. The nares are held open by means of a nasal 
speculum vv'hich is sufficiently well known to justify omission of a 
description at this time. The introduction of a solution of cocain and 
adrenalin is indispensable to a satisfactory examination. Its use is 
objectionable only on the ground that it obliterates minor degrees of 
hj^pertrophy of the nasal mucosa. Refinements in this connection are 
described in special publications devoted to the subject (Coakley,^ 
Ball,- Tilley^). 

Malformation of the Nose. — Malformations of the nose and naso- 
pharynx do not possess great surgical importance. Those of the 
septum are usually combined with other malformations. Perforation 
or total absence of the septum may be congenital, but is more likely 
to be due to perforating ulceration. Incomplete development of the 
turhmated hones is regarded as predisposing to ozena. Congenital 
coalescence of the inferior turbinated with the septum is not rare. 

Congenital atresia of the choanae is usually fibrous in nature, though 
bony obstruction has been observed (v. Eicken*). It is easily cor- 
rected by puncture with suitable instruments, including a specially 
constructed trephine. 

Injuries of the Nose. — Injuries of the nose in this connection are of 
importance only when they cause changes within the nasal cavity. 
This is especially likely to happen when the bones of the nose are 
fractured, i. e., the septum is "kinked" or fractured, or, what usually 
happens, the vomer is luxated from the quadrangular cartilage. Heal- 
ing with deformity is the rule and is followed by more or less nasal 
obstruction on the convex side of the injured septum. If the diag- 
nosis is made at once, the deformity may be corrected by tamponade of 

1651 



1652 SURGERY OF THE FACE 

the nostrils, and in severer eases, the nose is cocainized and the de- 
formity is corrected by manipulation, and this is followed by appro- 
priate tamponade. As injuries of this sort communicate with the nos- 
tril, infection is likely to occur. This may be prevented by cleanliness 
and frequent changing' of the tampon. 

Deviations and Spurs of the Septum. — Deformities of the septum 
occur most often at the junction of the crista and spina, where the 
vomer and quadrangular cartilage meet ; in addition to this, they also 
appear as the result of kinking of the cartilaginous septum, due to 
trauma and, in a certain number of cases, the anterior portion of the 
latter deviates to one side without an^^ assignable cause. 

The chief symptom of the lesion is interference with nasal respira- 
tion ; to this must be added certain reflex disiurhanccs, such as asthma. 
In all cases the surgeon must assure himself that the obstruction is 
actually due to the septal deformity and not to the presence of another 
lesion, such as hj^pcrtropliy of the turbinated bodies or polypi. 

The treatment varies with the degree of deformity. Small spurs or 
deviations may be removed with the chisel or other cutting instrument, 
provided the section does not perforate the opposite side. The grosser 
deformities are best treated by suhniucous resection (Killian''). A 
triangular flap, the anterior lower angle of which corresponds to a 
point just within the nares, is outlined on the mucosa of the septum 
and dissected up, together with the perichondrium and periosteum 
involving the deformit}^. The latter is cut off with cutting forceps or 
other instrument, care being taken not to invade the cavity on the 
opposite side. The flap is sutured back into place (see Nos. 1, 2 and 
3 of bibliography). 

Foreign Bodies in the Nose. — Of foreign bodies and rhinoliths, the 
former are most often introduced by children who force peas, shoe 
buttons, cherry pits and the like into the nostrils, where they lodge 
either in the nasal cavity or in the epipharjaix. Unless the child is 
observed introducing the body, the subsequent clinical picture may be 
mistaken for that of infection of the accessory sinuses. Occasionally, 
a therapeutic agent (gauze, etc.) is retained in the nasal passages. 
Particles of cement, chrome, and arsenic may accumulate in the nostrils 
of persons working with these substances. In this way, the formation 
of rhinoliths is caused. However, these are also developed as the re- 
sult of the incrustation of foreign bodies, clots of blood and inspissated 
mucus (Heymann*). 

The symptoms provoked by the presence of foreign bodies and rhino- 



THE SURGERY OF THE NOSE 1653 

liths consist in nasal obstruction and suppurative inflammation, liead- 
ache and neuraJgia. After a time, tlie intlammation becomes menac- 
ing and may extend to the accessory sinuses and the cranial contents, 
and, later still, the lesion takes on the form of a granulomatous process. 

Removal of the offending agent is not difficult. In children, nar- 
cosis is desirable ; in adults, cocainization of the nasal mucosa suffices. 
Tlie obstructed passage is illuminated and the foreign body is gently 
removed with a slender, blunt hook. To prevent forcing the body into 
the narrow portion of the passage, the hook is introduced above it. If 
the body is large it should be ernshcd before removal. 

Inflammations of the Accessory Nasal Cavities. — All of the accessory 
sinuses of the nose are susceptible to inflammation, either by extension 
from the nose or from other neighboring organs. 

In processes of this sort, occurring in connection with general in- 
fection, it is not possible to be certain whether the excitants travel 
from the nose into the sinus or whether the infection is direct. It is 
certain that by far the largest number of cases of inflammation of the 
accessory nasal sinuses occur in connection with influenza. Of the 
other diseases, scarlatina is the most frequent associated general in- 
fection (Dmochowski^). Of the local causes, extension from the teeth 
(dental origin) is no doubt the most important, although trauma 
(especially by projectiles), tuhercidosis, and lues are also responsible 
for the cundition (Hajek^). 

Acute Sinusitis. — Acute sinusitus, when not masked by the symp- 
toms of the underl3ang general disease, presents the clinical picture of 
a septic infection. Of the local symptoms, pain is the dominant factor. 
The pain is very severe. For instance, in involvement of the maxillary 
sinus, the entire side of the face aches as in acute pulpitis dentalis. 
Pressure over the afiPected sinus increases the pain. In infection of 
the frontal sinus, pain is most severe over the eye. Infection of the 
ethmoid cells is often attended with ciliary pain and injection of the 
conjunctiva. Acute infection of the sphenoid cells cannot be diagnos- 
ticated. Occasionally, the skin or mucosa over the affected sinus is 
edematous. Progressive osteomyelitis in connection with acute sinus- 
itis is very rare. Most cases of this sort are diagnosticated as neu- 
ralgia. The disease usually runs its course in two weeks. It is a 
regrettable fact that the affliction often escapes recognition even among 
well qualified practitioners. 

The diagnosis is not easy. It rests entirely upon the location and 
character of the pain and the marked increase in nasal secretion. 



1654 SURGERY OF THE FACE 

Transillumination, unfortunately, is unreliable. "When pus is present, 
the X-ray is of value. In doubtful cases, aspiration is of diagnostic 
and therapeutic value. One nostril is occluded and the air from the 
other is exhausted by means of a suction apparatus. Unless this is 
gradually done, pain is much increased for a time. 

The treatment is not satisfactory. Pain is relieved by anodyne medi- 
cation. Lavage of the affected sinus is contraindicated and, as a matter 
of fact, is too painfid. Drainage of the sinus is permissible only when 
secretion is retained and provokes menacing symptoms. It is most 
often necessary in frontal sinusitis occurring in connection with 
scarlatina. 
, Chronic Sinusitis. — Chronic sinusitis is most often a sequel to an 
acute infection, though it is occasionally tuberculous in character. 

The dominant symptom of chronic sinusitis consists in prolonged 
(.though intermittent) discharge of pus from the nose. Certain pos- 
tures of the head place the natural opening of the affected sinus at a 
Ipw point so that the contents evacuated and the discharge from the 
nose ceases for a variable period of time. The total quantity of dis- 
charge is often very large, the patient soiling a dozen handkerchiefs 
a day. The character of the discharge is tenacious, slimy and of a 
white or yellow color. At times, it is green or even bluish, and if 
bjood is present it is brown. Wlien cheesy masses are discharged, the 
term rhinitis caseosa is used. Not infrequently the secretion dries 
within the nose in the form of crusts presenting a picture not unlike 
that of ozena. Depending upon the condition within the nose, the 
secretion is discharged anteriorly or flows into the pharnyx. In the 
latter event it gains access to the larynx where it gives rise to chronic 
irritation. As a rule, the discharge is associated with a fetid odor, es- 
pecially when the lesion is located in the maxillary antrum. 

Chronic sinusitis rarely heals without operation. On the other hand, 
fatal complications, such as meningitis, thrombophlebitis, etc., are 
rare. Acute exacerbations are not uncommon ; spontaneous perfora- 
tion into the orbit or through the canine fossa into the mouth is not 
infrequent. Progressive osteomyelitis of the walls of the affected sinus 
is a grave complication, especially of the frontal, in which event, the 
process gains access to the cranium and may be responsible for extra- 
dural or cerebral abscess and suppurative thrombophlebitis. Seques- 
tration of the entire cranial vault has been observed in this connection. 
The treatment is taken up with the special sinuses. 

iSMPYEMA OF THE Maxillary Antrum. — Empyema of the maxillary 



THE SURGERY OF THE NOSE 1655 

antrum is the most common of the sinus infections. It mast be diag- 
nosticated from ostconiijclitis of the upper jaw. 

The spicial sijniptonis relate to the large quantity of the discharge 
and localization of the pain, which is most severe over the distribution 
of the second division of the trigeminus and in the teeth of the affected 
maxilla. The pain irradiates into the distribution of the supra-orbital 
nerve, but is less severe in this zone. Loss of smell is not constant but 
the patient is rarely aware of the odor which accompanies the dis- 
ease. 

The diagnosis is made by examination of the nose. When the nasal 
cavity is cleansed and pus is seen to emerge between the middle turbi- 
nated and the lateral wall of the nose, not from the fissure between the 
former and the septum, empyema of the sphenoid or posterior ethmoid 
cells may be excluded. If the secretion is ample, the anterior ethmoid 
cells may also be absolved. This reduces the possibilities to the frontal 
and maxillary sinuses, which is cleared up by placing a small tube 
into the ostium of the latter. If doubt still exists, the maxillary an- 
trum may be punctured through the nose. After cocainizing the 
mucosa, the hollow needle is plunged into the antrum just above the 
inferior turbinated body. If necessary, the antrum may be emptied 
with a sterile salt solution (diagnostic lavage). 

The treatment, at first, consists in frequent cleansing of the infected 
antrum through the ostium maxillare, a procedure which belongs to 
the domain of the specialist. If this fails, the antrum is opened ; local 
anesthesia is usually all that is necessary. 

Opening the maxillary antrum through the alveolar process is ac- 
complished by extracting either the second bicuspid or the first molar 
tooth, after which the cavity is entered by means of a burr, a trephine 
or a large drill. The diameter of the hole should not be less than 5 
mm. In making the opening the instrument must be directed slightly 
backw^ard. The cavity is kept clean; between treatments the patient 
wears a prosthesis, prepared by the dentist, which prevents the en- 
trance of food into the sinus and contracture of the drainage opening. 

Openirig of the maxillary antrum through the nose is credited to 
Mikulicz.*^ His method has been modified (Grant and Pegler") and 
today is practiced as follows : The anterior one third of the inferior 
turbinated body is removed with cutting forceps and the antrum per- 
forated at this situation with a specially constructed trocar (Fig. 804). 
The opening thus made is enlarged with the rongeur. The after treat- 



1656 



SURGERY OF THE FACE 



ment is directed toward keeping the opening patent until the process 
heals. 

Opening the tnaxillary antrum through the canine fossa is indicated 
in cases of chronic empyema in which prolonged drainage is necessary. 
Although the sinus was opened early in the last century (Desault"), 
the modem methods of accomplishing the purpose are based ou the 
work of Kiister.^^ An incision is made at the junction of the labial 
mucosa and alveolar process, extending from the canine tooth to the 
posterior molar; the mucosa and the periosteum are stripped up and 
the antrum is perforated with a burr or a gouge. This opening may 
be enlarged to any desired extent and is readily caused to communi- 
cate with one previoush' made from the nose (see 
above). The buccal flap of soft parts and another 
fashioned from the mucosa of the mouth may be 
turned into the sinus, a procedure which greatly 
facilitates ultimate obliteration of the cavity. Drain- 
age and accessibility to cleansing manipulations are 
facilitated by the introduction into the dependent 
opening of a metal obturator (Fig. 805B). 

Empyema of the Froxtal Sinus. — Empyema of 
the frontal sinus is most often the result of extension 
of infection from the nose, though it also develops in 
connection with general infections. It is often asso- 
ciated with a similar condition in the ethmoid and 
maxillary sinuses. 

In the treatment, lavage of the sinus is practiced. 
This, however, is not often effective, in which event 
the next step consists in resection of the anterior 
portion of the middle turbinated body and opening the anterior 
ethmoid cells. If this is not followed by relief, the frontal sinus 
must be invaded from without. As simple external opening of the 
sinus is usually followed b}' the formation of a fistula, the modern 
method of treatment aims at obliteration of the sinus or establishment 
of a wide communication with the na.sal cavity. As the former is not 
always successful, the operation most often practiced to-day is that 
of Killian,^^ which is a combination of the two. An incision down to 
the bone is made in the eyebrow area and is carried in a curve along 
the outer border of the nasal bone ; externally, the incision extends to 
the end of the eyebrow. The soft parts and periosteum above the eye- 
brow are elevated in accord with the size of the sinus, which varies 



Fig. 804. — Troc.'iR 
FOR Perforat- 
ing THE Maxil- 
lary Antrum 
(Wilemnisky). 



THE SrRGERY OP THE NOSE 



1657 



widt'ly aiul iniist be determined by X-ray before tlie operation. The 
sinus is opened with a gauge and chisel and its entire anterior wall 
is removed by means of bone cutting forceps. The mucosa is completely 
excised. Next, the skin at the lower aspect of the incision is turned 
down ; the periosteum over the inner aspect of the orbital cavity is left 
undisturbed. The soft parts are dissected back from the frontal pro- 
cess of the superior maxilla, care being taken not to injure the tendon 
of the superior obliciue muscle. Now the orbital portion of the sinus 
and the frontal process are carefully removed. The latter step ex- 
poses the frontal portion of the ethmoid cells and the anterior ethmoid 
labyrinth, which are converted into a single cavity. It now remains 
to establish commmiication between the frontal sinus and the nasal 
cavity. From the nasal mucosa, exposed by resection of the frontal 

process, a flap is fashioned 
the base of which is located 
downward; this flap is 
turned outward into the 
superficial wound, thus form- 
ing the desired wide com- 
munication with the nose, 
into which a drainage tube is 
introduced and the external 
wound is closed. The tube is 
removed on the third day. 
For additional methods see 
No. 8 of tlijB bibliography. 
Empyema of the Ethmoid Cells. — Isolated empyema of the eth- 
moid cells is very rare. They may be drained by resection of the 
middle turbinated body. From without they are invaded as a part 
of the operation for relief of infection of the frontal sinus (see above). 
Empyema of the Sphenoid Cells. — Empyema of the sphenoid 
cells alone is not as rare as that of the ethmoid, but nevertheless, it 
occurs most frequently in combination with infection of one or more 
of the other accessory sinuses. 

Aside from the symptoms common to multiple or pansinusitis, 
chronic infection of the sphenoid cells is characterized by the dis- 
charge of fetid material into the nose and the deposit of crusts. The 
clinical picture resembles that of ozena, and is, indeed, very often a 
complication (or perhaps a cause, Hajek^) of the latter condition. As 
a rule, the condition is attended with an atrophic, rather than a hj-per- 




FiG. 805. — A, Opening into the Maxil- 
lary Antrum with Obturator in situ. 
B, Obturator. 



1658 



SURGERY OF THE FACE 



trophic condition of the nasal mucosa. Of the subjective symptoms, 
disturbances of vision, i. e., scintillation and amblyopia, have been ob- 
served. While the connection is not definite, not a few rhinologists 
express themselves as convinced of an association of this sort 
(Holmes"). 

Invasion of the sphenoid cells and their drainage may be accom- 
plished from the nose without much difficulty, especially when the 
middle turbinated body is atrophied or is removed. However, the pro- 
cedure belongs essentially to the field of the rhinologist. See bibli- 
ography, Nos. 1, 2, 3, and 8. 

Ulceration and Infectious Granulomata. — Destructive and granulo- 
matous processes are usually located at or 
near the entrance to the nares. Of these, 
simple perforating ulcer is the most common. 

Simple Perforating Ulcer. — Simple per- 
forating ulcer is due to a chronic inflamma- 
tory process, a sort of seborrheic eczema, 
maintained by manipulations with the finger 
nail on the part of the patient. Is is usually 
seen in children, but it also occurs in adults 
who work in an atmosphere laden with 
arsenic dust, etc. In the latter class of 
cases considerable areas of the nasal cartilage 
"become necrotic and the process is often 

attended with sharp hemorrhage. The treat- ^^^ g^g _ killian 's Op- 
ment consists in removal of the cause. eration for Frontal 

Tuberculous Ulcers. — Of the specific Sinusitis. 

, , - . . The flap of nasal mucosa 

ulcerations, the tuberculous is the most com- jg \^(,\^ by a tenaculum. 

mon. It is most often associated with ad- 
vanced lung tuberculosis, but may occur primarily in the nose, where 
it usually appears upon the cartilaginous portion of the septum, the 
lower turbinated body, or the floor of the nose. The ulcer bears some 
resemblance to lupus, but is likely to present a granulating surface; 
some of the granulations reach the size of a cherry. In not a few 
instances, multiple ulceration is present. 

The milder forms of tuberculous ulceration of the nose heal after 
thorough curettement and the application of gauze saturated with 
20 per cent pjnrogallic acid. The severer forms are always associated 
with advanced lung lesions and are only susceptible to palliative 
measures. 




THE SURGERY OP THE NOSE 1659 

Sypiiillitic Ulceration, — Syphilis is localized in the nose usually 
iu the form of a tertiary manifestation, although chancre may also 
occur ill this situation. In the latter instance the infection is no doubt 
carried by the finger nail. 

In the icrliaru stcujc of the disease the nose is usually ulcerated, 
though occasionally a syphilitic granuloma is found. The lesion 
occurs primarily- as a gumma in the cartilage or bone, especially in 
the septum near the floor of the nose. Many of these perforate into 
the mouth and not a few destroy the bony framework of the nose. 
The treatment consists in energetic antiluetic medication, especially by 
the injection of mercury. Subsequently, the resultant deformity is 
subjected to plastic repair. 

Granulomata of the nares occur in connection with lues. They 
usually arise from the turbinated bodies and are frequently multiple. 
Aside from those of luetic origin, tuberculosis, glanders, and lepra are 
the most common underlying causes of the peculiar infectious hyper- 
plasia. The diagnosis is only possible with the aid of the microscope. 
Many writers include bleeding polypi and scleroma in the granulo- 
mata ( see chapters devoted to lepra, scleroma, and glanders). 

Nasal Hemorrhage. — In 80 per cent of the cases, nasal hemorrhage is 
due to simple ulcer and the polypoid growths developing in connection 
with it. This consideration suggests that an effort should be made to 
control the bleeding by firm anterior tamponade and that posterior 
tamponade should be postponed until it is shown that the former does 
not accomplish the purpose. It is, however, necessary that the an- 
terior nares be thoroughly tamponed before the next step is taken. 
Of the various materials used for tamponade, there is none more effec- 
tive than iodoform gauze. If the bleeding persists, the anterior 
tampon is removed, the nasal cavity washed with 2 per cent gelatin 
in normal salt solution, and the posterior nares tamponed by means of 
a Beloc cannula or, which is simpler and perhaps more desirable, by 
an ordinary soft rubber catheter passed through the bleeding nasal 
passage and "fished out" of the pharynx with the finger. To this 
the string to which the tampon is attached is fastened and delivered 
out of the nose as the catheter is withdrawn. Saturating the tampon 
with thromboplastin is of great value. 

Benign Tumors of the Nose. — Fibromata of the nose are rare. As a 
rule so-called fibromata spring from the periosteum or perichondrium 
of the nose and consist of laj^ers of connective tissue fibers. Myxo- 
iuata hjmphangiectatica are occasionally encountered. Enhhondromata 



1660 



SUEGERY OF THE FACE 



are equally unusual. On the other hand, osteomata are not uncommon. 
They usually develop from the walls of the accessory sinuses and are 
often pedunculated. Tumors of this sort cause tremendous distortions 
of the face. The diagnosis is made with the X-ray. 

The operative removal of large benign tumors of the nose is very 
difficult and involves sacrifice of the facial bones. The smaller in- 
tranasal fibromata or chondromata may be removed with the snare. 

Nasal polypi are very common. The line of demarcation between 
these tumors and polypoid hypertrophies of the mucosa due to chronic 
inflammatory processes is not clearly defined. Most of the growths 
are pedunculated, though many of them are attached by a broad base. 
As a rule, they appear in multiple form ; on the other hand, a solitary 
polypus may reach enormous dimen- 
sions and grow into the epipharnyx. 
The latter class of tumors often arises 
within the maxillary antrum. 

Ordinarily polypi are henign in 
character but are difficult to get rid 
of. The prevailing belief that they 
always recur is erroneous. If the 
growths are completely extirpated 
they do not return (KiimmeP^). 

The dominant symptom of nasal 
polypi is obstruction to breathing. To 
this may be added the discharge of a 

clear mucoid fluid from the nose. This leads to examination which 
readily reveals the nature of the lesion. 

The treatment of typical polypi which do not originate in the 
accessory sinuses consists in intranasal extirpation with the cold snare; 
the older "polypus forceps" has been discarded. Tbe nose is cocain- 
ized and illuminated and the snaring is accomplished "under the 
eye." "When multiple polypi are present, the operative measure is 
repeated at intervals, until all the growths are removed. In polypi 
located in the epipharynx, application of the snare is difficult. In these 
instances the growths must be grasped with forceps and forcibly 
twisted out. If the polypoid growths are due to sinus infection, relief 
from the latter prevents recurrence of the former. 

Malignant Tumors of the Nose. — Sarcoma originating within the nose 
is exceedingly rare (Heymann^). 

Carcinoma of the nasal passages is usually of the horny, flat, epithe- 




FiG. 807. — Intranasal Polypi. 



THE SURGERY OF THE NOSE 1661 

lial type. This is explained on the ground that the prolonged presence 
of an acute iiiHauimatory process converts the ciliated epithelium nito 
that of the epidermal type before the carcinoma develops. In Uie 
accessory sinuses carcinoma is of the cylindrical cell type. 

The symptoms at first consist in nasal obstruction and deformations 
from pressure which occur early and increase rapidly. Soon the 
process takes on a destructive form, invading the contiguous sinuses, 
soft parts, and bones until the loss of substance is very extensive, 
including the eyeballs, the forehead and the bones of the cranium, 
often exposing the brain. Tumors originating in the accessory sinuses 
at first present the picture of sinusitis until the process gains access 
to the nasal passages. Involvement of the various cranial nerves is 
attended with pressure s;>Tnptoms, and, later, with paralysis. 

The clinical picture of malignant disease of the nose and its acces- 
sory sinuses is not distinctive until the process has advanved to a 
considerable extent, and the differential diagnosis is by no means easy. 
The presence of a tumor involves taking into account the large num- 
ber of processes already taken up, of which benign tumors, tubercu- 
losis, luetic lesions, granuJomata, and polypi are of especial import- 
ance. The microscope is of course of the greatest assistance in this 
connection. 

Preliminary Operative Exposure of the Interior of the Nose. — 
The development of rhinological technic has narrowed the field of 
operative exposure of the nasal passages to a considerable extent, and 
its usefulness is limited to making those tumors accessible which must 
be radically removed or which are of such dimensions as to render 
endonasal extirpation impracticable. Many of the methods available 
for the purpose are also used for approach to the nasopharynx. These 
are alluded to elsewhere. At this time the technic for exposure of the 
nasal passages alone will be given a brief consideration. 

Section and separation of the soft parts of the nose in the median 
line, or the elevation of a wing of the nose at its insertion, does not give 
much room. It is rarely practiced at this time. Somewhat better ex- 
posure is attained by making an incision M'ithin the mouth, which 
loosens the upper lip, sectioning the septum and elevating the entire 
soft parts of the nose (Rouge^®). 

Section and Separation of the Entire Nose gives more room than 
the method just described (Koenig^'^). The soft parts of the nose 
are split from root to tip ; the nasal bones are separated from the 
frontal process, the nasal process of the superior maxilla is divided. 



1662 SURGERY OF THE FACE 

and one half of the nose is displaced laterally. The opposite nasal 
passage may be exposed in a similar manner. The method most fre- 
quently employed is that of v. Bruns.^* An incision is carried from 
the inner angle of the eye across to the opposite side and then around 
the nose through the septal attachment at the upper lip. The nasal 
bone and septum are divided in the line of the incision and the entire 
nose turned to the opposite side. This gives a fair exposure and, after 
the intranasal manipulations are completed, the nose is replaced and 
sutured. The cosmetic result is good. 

BIBLIOGRAPHY 

1. COAKLET. Dis. of the Xose and Throat, N. Y. and Phila., 1908. 

2. Ball. Dis. of the Xose and Pharynx, N. Y., 1906. 

3. TiLLET. Dis. of the Xose and Throat, London, 1908. 

4. V. EiCKEX. Yerh. d. Yereins deutsch. Lai-ATigol., 1911. 

5. KiLLiAX. Arch. f. Lar^^l. u Rhin. xvi, 1904. 

6. Heymaxx. Handb. d. Laryn. u. Rhin. iii. 

7. Dmochowski. Same as Xo. 6. 

8. Hajek. Erkrank d. X'ebenhohlen d. Xase, Yienna, 1909. 

9. Mikulicz. Quoted by Xo. 8. 

10. Graxt and Pegler. Semons Zentrbl., 1899. 

11. Desault. Chir. X'achlass, 1880, ii. 

12. KusTER. Deutseh. med. AYoeh., 1889. 

13. KiLLiAX. Arch. f. Lar^-nsrol.. 1902, xiii. 

14. Holmes. Arch. f. Opthalmol., 1896, xxv. 

15. Kf MMEL, in Handb. d. prakt. Chir., Stuttgart, 1913, i. 

16. Rouge. Quoted by Xo. 15. 

17. KoEXiG. Handb. d. spec. Chir. L 

18. V. Bruxs. See Xo. 17. 



CHAPTER IX 
THE SUKGEKY OF THE MOUTH 

Malformations and Congenital Affections of the Mouth. — Branchio- 
geiious clefts involving the mouth liave already been taken up (p. loitlj). 
This leaves for consideration ahseiice of the tongue, cleft tongue 
{lingua bifida), adhesions of the tongue, ankyloglossia, enlargement of 
the tongue, and cpignathus. 

Absence of the tongue is usually associated with other defects, such 
as cleft palate (Griffith^). 

Cleft tongue is the result of a failure of coalescence of the sides of 
this organ It has been obsei^A^ed alone and in connection with congeni- 
tal separation of the lower jaw. Limitation of the deformity to the 
tongue is fully described by Pooley.^ It must not be confused with the 
deep furrow which at times Is found in the tongue in tertiary lues. 

Congenital pedunculation of the tongue is a peculiar soft enlarge- 
ment of the anterior portion of this organ. 

Adherent tongue is a term applied to a condition in which the lower 
surface of the tongue merges with the floor of the mouth, or in which 
the tongue is adherent to the sides of the lower jaw by bands of 
greater or lesser dimensions ; not infrequently, the entire under sur- 
face of the tongue is "glued" to the floor of the mouth in this way. 
In these cases it is usually only necessary to separate the imprisoned 
organ from its restricting attachments with the finger. However, if 
any of the bands are particularly resisting, they may be divided with 
scissors. The normal mobility of the tongue prevents its readherence. 

Ankyloglossia is a term applied to a condition in which the lower 
anterior aspect of the tongue is adherent to the floor of the mouth 
by a short, broad frenulum (''tongue tied" of the laity). "When the 
tongue is protruded it curves downward. These cases must show 
difficulty in nursing or speaking before they are interfered with. Sec- 
tion of the frenulum is undesirable, and fortunately is gradually be- 
ing added to the list of forgotten operations. 

Congenital enlargement of the tongue was first described by Petit 

1663 



1664 SURGERY OF THE FACE 

in 1742 (quoted by Girod^), who reported three cases in whicli the 
patients were in danger of suffocation from "swallowing the tongue." 
The condition would seem to be an increase of the parenchyma of the 
tongue (WelzeP). Lengemann'^ has practiced wedge shaped excision 
for relief of the affliction with success. 

EpignaiJius, or ppotruding tongue, is usually a complication of 
other congenital malformations, such as encephalocele. It may be 
sufficiently marked to interfere with respiration. Resection of the 
tongue is not usually undertaken, because of the associated malforma- 
tion. 

Wounds, Burns, Scalds and Chemical Cauterization of the Buccal 
Mucosa. — Wounds of the buccal mucosa, that is, injuries restricted 
to this membrane, heal with astonishing rapidity, despite the active 
bacterial flora in the mouth. However, infection does occur in this 
situation, especially when the bone is injured. On the other hand, a 
wound produced elsewhere on the body by the teeth is very likely to 
be infected, which suggests that the mouth possesses a natural resisi- 
tance to its "own bacteria," and that the latter possess considerable 
virulence in other environments. No doubt the great vascularity' of 
the mouth presents an important defensive factor (Hunter*'). Efforts 
at chemical sterilization of the buccal mucosa lessen its resistance to 
infection and, for this reason, mechanical cleansing is far more de- 
sirable. However, even the latter must not be attended with trauma. 

The mouth is of course the seat of all kinds of wounds and no 
special classification is necessary in this connection. In deep wounds 
of the tongue, hemorrhage is the most important complication. This is 
attended with three possibilities, (1) exsanguination, (2) aspira- 
tion of blood into the lungs, (3) bloody infiltration of the paren- 
ch3Tna of the tongue. All of these may be obviated by thorough hemo- 
stasis. For the purpose, the tongue is delivered from the mouth, using 
a transfixion loop of silk if necessary. The employment of the suture 
ligature (p. 38) is especially useful in this situation. Persistent 
bleeding may demand tracheotomy in order to prevent asphyxiation, 
due to the flow of blood into the lungs. Primary hemorrhage is usu- 
ally readily controlled; on the other hand, secondary bleeding is 
always a menacing condition, often controllable only by ligature of 
the lingual artery in the nech (p. 1029). 

The lodgme/)\t of foreign todies (fish bones, needles, etc.) in the 
tongue is a very frequent occurrence. They should be promptly re- 
moved under local anesthesia. 



THE SURGERY OF THE MOUTH 1665 

All FRESn WOUNDS OF THE TONGUE, INCLUDING THE CONTUSED AND 

LACERATED, SHOULD BE SUTURED, Oil the gTOuiid that the great vascu- 
larity of this organ and its resistance to infection makes uninterrupted 
repair a reasonable certainty. The fibrinous deposit seen on the wound 
a few days later does not interfere with healing; it corresponds to the 
scabs formed on superficial wounds situated elsewhere. Partial avul- 
sion or amputation of the tongue, frequently due to injury from the 
teeth (fall or blow), is especially interesting in this connection, as re- 
placement and suture of portions of the organ attached by even a 
slender pedicle are usually followed by healing. Wasp stings of the 
tongue are at times followed by such enormous swelling that respira- 
tion becomes seriously impaired, demanding relief by temporary trach- 
eotomy. Return to the normal is the rule, though liberal incision, 
giving egress to the fluid exudate, may be necessary. 

Ulceration of the tongue at the frenulum, due to prolonged friction 
against irregular teeth during an attack of pertussis, is often seen. 
The ulcer should be painted with 25 per cent silver nitrate, which is 
almost immediately neutralized with milk. This prevents infection 
which, when it occurs, is likely to extend very rapidly and has been 
known to destroy the entire tongue. Indeed, decuhital ulceration, the 
outcome of friction against carious teeth, etc., should be given imme- 
diate attention. The condition heals at once when the cause is re- 
moved. So-called Fede's'' disease, no doubt, belongs to this category. 

Thermal hums of the buccal cavity occur in connection with the 
introduction of hot substances, usually fluid, and the entrance of hot 
vapors (see Pitt's^ collection of cases). They possess especial interest 
because of involvement of the epiglottis, the air passages, the pharynx 
and the esophagus. These often demand immediate tracheotomy. 

Pain in burns of the mouth is always severe, but soon disappears, 
except that deglutition remains painful. Cold (sterile) water affords 
considerable relief. Blebs rupture early. The epithelium soon as- 
sumes a grayish yellow color and insular areas form crusts, which 
soon exfoliate. If ulceration persists, these are treated as are benign 
ulcers. 

Chemical cauterization follows the introduction into the mouth of 
corrosive substances (concentrated alkalies and acids). TTie lesion is 
likely to be extensive and is attended with much the same picture as 
heat produces, except that swelling and redness are likely to be marked. 
Involvement of the epiglottis, the pharjTix and the esophagus is more 
frequent in these instances than in the thermal injuries. During the 



1666 SURGERY OF THE FACE 

repair the coalescence of the various structures of the mouth should 
be obviated as far as possible. Earlj^ plastic repair by sliding of the 
healthy mucosa is desirable. 

Nonia is taken up in Part II, chap. xii. 

Lues of the Mouth. — Lues of the mouth is not exclusively a venereal 
disease. Of one hundred cases of non-venereal lues, collected by 
Miinchheimer,'' thirtj^-nine occurred in the mouth in the following 
order of frequenc}^ lips, tongue, palate, cheek, gums. The carrier 
of the infection is very varied, including table silver, towels, handker- 
chiefs, etc. Direct infection (kissing, etc.) is probably the most com- 
mon mode of contracting the disease. 

The primary lesion does not differ from that located elsewhere in 
the body. When lues is suspected, the combination of the serological 
test, microscopical examination of a smear taken from the chancre, 
and the action of salvarsan should follow in sequence. In the 
mouth a papillar\^ sM^hilid and the primary chancre may coexist 
(Fournier"). 

Late forms of the disease possess the greatest surgical importance. 
Luetic lesions of the mouth appear as circumscribed gummata or in 
the form of diffuse gummatous infiltrate. Late lues of the lip usually 
begins in the corner of the mouth and gradually extends over its en- 
tirety. Gumma of the cheek perforates very early and takes on the 
form of a serpiginous ulcer. 

Lues of the tongue, of the superficial and deep types, appears in 
the form of a nodule or nodules. Multiplicity of the lesion excludes 
actinomycosis and carcinoma. The deeper the gumma is located, the 
larger it is likely to be. The gummata grow slowly (size of a walnut) 
and are covered with apparently normal mucosa, until they break 
down which usually occurs in the center of the nodule. The subse- 
quent behavior of the lesion is that of luetic ulceration (see Part II, 
chap. xxv). In the differential diagnosis, actinomycosis, tuberculosis, 
rhagades, and the ulcerative type of carcinoma must be taken into ac- 
count. Aside from the constitutional treatment of luetic lesions of 
the mouth, curettage of the ulcers and excision of thickened areas are 
helpful measures (Morillon," v. Mikulicz and Kiimmel"). 

Tuberculosis of the Mouth. — Primary buccal tuberculosis is rare. 
When one considers that the causative bacillus passes through this 
cavity en route to its lodgment within the body, this is an astonishing 
fact. No doubt the natural resistance of the mouth to infection, 



THE SURGERY OF THE MOUTH 



1607 



spoken of above, is an important factor in this connection (Hilde- 
brand"). 

Secondary tuberculosis of the mouth develops in three ways, (1) 
extenswn of lupus from the fa^ce, (2) the passage of tuberculous 
sputum, from the lung, and (3) by way of the blood. 

The lesion appears in the form of a single nodule or of numerous 
small, round ulcers. 

The tuberous form of conglomerate tubercles is almost always located 
at the edge of the tongue and closely resembles a gumma, beginning 
carcinoma, or an area of inflammatory thickening. Desirable as it is 

to recognize the character of 
the lesion at once, as a rule this 
can be ascertained (after re- 
moval of the offending process) 
only by the microscopical find- 
ings. It is true that the tubercle 
is very likely to be surrounded 
by a zone of inflammation. 
However, this is not determin- 
ing as regards the diagnosis. 
The course of the lesion, after 
it breaks down, is more indi- 
cative. The secondary ulcer is 
characterized by undermined, 
edges, thin rim, '' slit-like" 
form and grayish ivhite base. 
However, even these character- 
istics are not unlike those of a 
luetic lesion. Coexistence of laryngeal and pulmonary tuberculosis is 
so common that the mouth lesion might well be the outcome of an 
accidental complication. 

Tubercidous ulcerations of the mouth are exceedingly painful, espe- 
cially when they develop secondarily to the nodular form. They 
interfere with the taking of nourishment — a most serious condition 
of affairs for obvious reasons. 

In making the diagnosis, observations of the clinical course of the 

disease, the results of the v. Pirquet and the Wassermann tests, and 

the microscopical findings are taken into account. The coexistence of 

tuberculosis and lues has been shown by Garel and Armand.^* 

The treatment, aside from palliative measures to lessen pain, and 




Fig. 808. 



Tuberculosis of the 
Tongue. 



1668 SURGERY OF THE FACE 

the employment of a non-irritating diet, consists in curettage and 
excision of the lesion. In advanced cases extirpation of the entire 
tongue must be considered. 

Actinomycosis of the Mouth. — In most instances buccal actinomj'- 
cosis is a part of a general involvement of the cheek, the maxillae, and 
the neck. As a rule, the actinomycotic fungus gains access to this 
region through the mucosa of the mouth and the pharynx (Illich^^). 
The bacteriology' and general clinical behavior of the disease is taken 
up in Part II, chap. xix. 

Usually the primary port of entrance of the infection heals sponta- 
neoush'; soon, however, the tissues at or near the site of entrance are 
involved in a board-like swelling, which presently breaks down in the 
form of more or less numerous abscesses, while the infection progres- 
sively invades the tissues in all directions. Thus, the cheek, the tongue, 
the floor of the mouth, the soft palate, and so on, are gradually in- 
volved and become the seat of necrotic areas and fistulae. The 
progress of the disease is essentially' chronic in character. 

The diagnosis of actinomycosis is made certain by recognition of the 
causative ray fungus. Unless this is done, it is difficult to diagnosti- 
cate the affection from lues, tuberculosis, and various tumors, including 
malignant diseases, at least not before the more menacing conditions 
have advanced sufficiently to render relief impossible. 

For treatment see page 411. See also Latte and Barret,^'' Levy,^^ 
and No. 12 of the bibliographj^ 

Phlegmonous Glossitis. — Superficial glossitis, attended with redness, 
epithelial exfoliation, papillary swelling, and fibrinous deposits, 
occurs in connection with almost all infectious diseases. T'he affection 
has been burdened with a number of fanciful names, such as lingua 
geographica, cat tongue, hair tongue, etc., the outcome of the imagina- 
tion of the rhinolarj-ngologist. It possesses no surgical importance, 
except in as much as it forms a part of the more serious deep glossitis. 

Deep glossitis (glossitis profunda phlegmonosa) may be the result 
of trauma. It occurs most frequently in connection with erysipelas 
of the mucosa of the mouth, the latter being invaded by extension 
from the face. This form of glossitis rarely suppurates. 

A special form of glossitis — hemiglossitis — is characterized bj' a 
sudden swelling of one half the tongue. It runs a stormy course for 
three days and then subsides. The condition is ascribed by Giiter- 
bock^^ to nervous influences (analogous to herpes zoster). 

So-called mouth and hoof disease (more or less widely distributed 



THE SURGERY OF THE MOUTH 1CG9 

among cattle) also belongs to the category of plilegmonous glossitis. 
The disease is epidemic and is preceded by a prodromal stage, indi- 
cating the development of an acute infectious disease. This is fol- 
lowed by the appearance on the tongue of a vesicular eruption, which 
also covers more or less of the mucosa of the rest of the mouth. In 
women, the eruption also appears on the nipples and on the vulva. 
Exfoliation of the blisters is followed by ulcertation and this seems to 
provide an avenue of ingress for streptococci. In this event, the 
disease presents the clinical picture of a severe, deeply located phleg- 
monous glossitis. The mortality is high — 33 per cent (SiegeP''). 

Suppurative phlegmonous glossitis, despite the many injuries to 
which the tongue is subjected, is comparatively rare. When the infec- 
tion is limited to the preepiglottic region, deglutition is painful and 
this causes the condition to be mistaken for angina. When an abscess 
develops in this situation, the symptom of fever, together with swell- 
ing of the cervical lymph nodes, is presented. As the tongue lesion 
increases, the epiglottis is very likely to be involved, so that respiration 
becomes seriously embarrassed and, in not a few instances, tracheotomy 
is imperative. In the milder forms of the affection the disturbances 
are limited to pain and limitation of the mobilit}^ of the tongue. In 
the more severe forms of glossitis the entire tongue swells and may 
be so large as to protrude from the mouth. In these instances the 
tongue is forced between the teeth, and presses the floor of the mouth 
downward and backward against the palate and the larynx, causing 
respiratory difficulty without the occurrence of edema glottidis. Of 
course, speech and deglutition are impossible. 

The dangers of the condition are readily understood. Aside from 
the menace as regards respiration, the process is very likely to extend 
from the floor of the mouth and to descend into the necl', while 
Ludwig's angina usually begins with a periodontitis, the disease 
infects the floor of the mouth before descending in the neck, from 
where it invades the loose alveolar tissue in the region of the sub- 
maxillary triangle and usually does not let the tongue escape entirely. 
This would indicate that perhaps so-called Ludwig's angina is not as 
clearly defined a clinical entity as has been supposed — a notion the 
writer is inclined to share. The last, but not by any means the least, 
danger of phlegmonous glossitis is that of aspiration pneumonitis. 

The treatment of phlegmonous glossitis must be radical. Despite 
the attendant pain, the finger is forced through the angle of the mouth 
and is "hooked" behind the base of the tongue. Under the guide of 



1670 SURGERY OF THE FACE 

the fiiiger a scalpel is iiitroduced (sideways) as far back as possible, its 
cutting edge turned downward and the dorsum of the tongue deeply 
incised as the knife is withdrawn. The incision is made in the median 
line unless one side of the tongue is more swollen than the other, when 
the incision is made through the zone of greatest swelling. Even 
though pus is not discharged, the incision gives exit to sufficient exu- 
date to afford relief. AVhen healing occurs, the resultant scar is barely 
perceptible. Bleeding, unless menacmg, is encouraged; if this be- 
comes alarming, tamponade readily accomplishes hemostasis. If 
respiration is embarrassed, tracheotomy is performed before the lib- 
erating incision is made. If no contraindication exists, tracheal 
narcosis may then be employed and the tongue incised with less haste. 
If the infiltration has invaded the submental or submaxillary regions, 
these must also be freelj' incised. As may be expected, the vascularity 
of the tongue renders gangrene a rare occurrence. 

Glossitis hemorrhagica consists in a rare bloody extravasation into 
the parenchj-ma of the tongue occurring in connection with hemo- 
philia. The tongue may become so distended that, despite the danger 
of persistent bleeding, it must be incised (Umbreit'"). 

Hemangiomata of the Mouth. — Simple hemangiomata (telangiec- 
tases) appear on the tongue in the form of small, slightly elevated 
spots, somewhat darker in color than the surrounding normal mucosa. 
They are usually associated with a similar condition in the mucosa of 
the cheek, though the latter are, as a rule, larger in size. In most 
instances, the simple form of the lesion is superimposed upon an 
underlying hemangioma cavernosum situated in the submucous tissues. 
The tumors always increase in size when the head is lowered and they 
may be emptied by pressure ; as soon as the pressure is released the 
dilated vessels are again filled up (see Part VI, chap. x). 

The clinical importance of hemangiomata lies in their tendency to 
extend in all directions. They often assume gigantic proportions. 
The very objectionable unsightliness of the affliction is the least im- 
portant factor in the problem. Tumors of this sort are very likely to 
Meed in large quantities and readily infect, and therefore are danger- 
ous to life. 

Hemangiomata should, when possible, be extirpated. The technie 
of the procedure does not differ from that employed for the removal 
of other growths in this situation. For ignipuncture, injections of 
alcohol, and the use of magnesium pencils see page 1163. 

Lymphangiomata of the Mouth. — In the mouth, lymphangiomata 



THE SURGERY OF THE MOUTH 



1671 



appear in the cystic and cavernous forms. Cystic lymphangiectasis 
appears as simple cysts which correspond to dilated lymph vessels, are 
lined with a single layer of epithelium, and contain a serous fluid. 
They are pi'obably retention cysts and may reach a considerable size. 
In addition to this, cystic lymphangiomata appear in the form of warts 
and nodules, either disseminated over the entire tongue or collected in 
groups at the side and on its edge. The cysts usuall}" rest upon a base 
of indurated tissue, which is the outcome of a low grade of inflam- 
mation. 

Both forms of the lesion are congenital in origin, but grow so slowly 
that they do not attract attention until they achieve a certain size or 

become inflamed. The latter is 
always due to an accidental in- 
fection (Kiittner-^). This may 
assume alarming proportions 
and present the clinical picture 
of a phlegmonous glossitis. 

The smaller cysts and nodules 
may be destroyed with the 
cautery; the larger ones are best 
extirj^afed. 

Macroglossia. — Cavernous an- 
gioma of the cheek is called 
macromelia; of the lip, macro- 
cheilia ; and when the tongue is 
involved the term macroglossia 
IS employed. 

Macroglossia is congenital in 
origin, but usually does not 
attract attention until the tongue protrudes beyond the teeth. The pro- 
truding portion of the tongue is dark in color and covered, with fissures, 
excoriations, and ulcers. The intrabuccal part of the organ is indented 
by the pressure of the teeth and alveolar processes. If the dorsum of 
this portion is \dsible, it is found covered with numerous vesicles. 
The process may cause little or no disturbance for years and then, 
suddenly, a rapid increase in size or an intercurrent inflammation 
causes the tongue to become a great hindrance to function or, if the 
infection is severe, may menace life in a manner described in connection 
with phlegmonous glossitis. 

Histologically the process does not differ from Ijonphangiomata in- 




FiG. 809. — Macroglossia, 



1672 SURGERY OF THE FACE 

volving other portions of the body. Muscular and neurofibromatous 
macroglossia are verj- rare. 

As a rule, macroglossia affects only the anterior portion of the tongue. 
It may also be restricted to certain areas of this organ and simulate 
other forms of growths. 

The treatment of the smaller cavernous lymphomata consists in 
destruction by the cauterA- or by excision. In the severe forms of 
lymphangiomatous macroglossia repeated wedge shaped excision of 
the enlarged tongue is practiced. Most surgeons precede the primary 
operation by ligature of both lingual arteries, a measure which sim- 
plifies the subsequent problem considerabh'. 

Mucous Cysts of the Mouth. — ^Mucous cysts appear on the mucous 
surfaces of the lips and cheeks and occasionally on the edge of the 
tongue. The tumors are round in form, fluctuate, and are often bluish 
m color. They contain a clear, ropy mucus and belong to the class of 
retention cysts of the mucous glands. 

In making the diagnosis, cysts of this nature must not be mistaken 
for hemangiomata. The treatment consists in extirpation which is 
readily accomplished under local anesthesia. 

Cysts of the back of the tongue in the region of the foramen cecum, 
the so-called lingual tonsils in front of the epiglottis, possess great 
surgical significance. They originate in the small mucous glands of 
the crypts of the tongue, in the larger mucous glands between the 
papillae, and in the remains of the thyroglossal duct. The latter form 
is lined with ciliated epithelium (Schmidt--). Cysts of this nature 
irritate the epiglottis and are often responsible for persistent cough. 
Thej'' are discovered by examination with the mirror and are easily 
extirpated with appropriately fashioned scissors. 

Echinococcus cysts of the mouth are exceedingly rare. 

Ranula. — The term ranula (batrachos hypoglossis, frog swelling, 
grenouillette of the French) is applied to a sublingual cyst which occu- 
pies the space between the frenulum and the mental portion of the 
lower jaw, pushing the tongue upward. The cyst usually develops on 
one side and gradually crosses the median line. Its outline is made 
asymmetrical by the constriction of the frenulum. The large cj'sts 
bulge beneath the jaw. Occasionally, a ranula develops in the median 
line. 

As a rule, "Wharton's duct may bo probed as it lies on the top of the 
transparent cystic enlargement (Fig. 810). The cyst itself appears as 
a transparent protrusion, grayish or bluish red in color, with the blood 



THE SURGERY OF THE MOUTH 



1673 



vessels distinctly visible in the superimposed mucosa of the floor of the 
mouth. The contents of the cyst is visible shimmering through its 
covering and conveys the idea of a blister. As a rule, the cyst is uni- 
locular, though occasionally it is divided into multiloculi. The fluid 
does not contain ptj-alin or rhodan kalium. 

Ranula occurs at all times of life and may be congenital. Its growth 
is slow but stead}', so that the disturhances, which at first are minor, 
may, and indeed often do, assume considerable proportions. These con- 
sist in interference with nourishment, and ultimately with respiration. 
When infection occurs, which is by no means rare, the clinical picture 
assumes that described in connection with phlegmonous glossitis, espe- 
cially its complications. If the 
ranula develops in childhood, its 
presence interferes with develop- 
ment of the jaw (atrophy). 

The presentations of the patho- 
genesis of ranula have been so 
varied, that the views held at this 
time may properly be stated 
briefly as follows: (1) that it is 
a cyst consisting of dilated Boch- 
dalek's tubules lined with cilated 
epithelium, which probably is cor- 
rect (Neumann^^) ; (2) that is is 
a dilatation of the Bland in-Nuhn 
gland, which probably is not cor- 
nect (v. Recklinghausen^*) ; (3) that it is a chronic inflammation of 
the sublingual gland, w^hich probably is correct (v. Hippel,^-^ 
Morestin^*'), The theory that ranula is a retention cyst of the sub- 
Imgnal gland has been abandoned. 

The differential diagnosis takes into account tumors of various kinds 
located in this situation. Though solid growths should be easily diifer- 
entiated, cysts of other kinds than ranula are not so readily separated, 
nor is confusion with angiomata and lymphangiomata always easily 
avoided. However, attention to detail in studjang the characteristics 
of the growth should prevent an erroneous conclusion, except perhaps 
with respect to dermoids of the floor of the mouth, in which the char- 
acter of the contents clears up the situation. 

The treatment consists in extirpation of the cyst through the mouth. 
This may usually be accomplished under novocain-adrenalin local anes- 




%■ 



Fig. 810. — Ranula: Probe in 
Wharton's Duct. 



1674 SURGERY OF THE FACE 

thesia. When, however, the cyst is a part of the suHmgual gland, the 
latter is best excised in toto through an incision beneath the jaw. 

Dermoids of the Mouth. — In 1908 Debonelle-^ collected seventy-seven 
cases of dermoid cysts of the mouth. They are the outcome of inversion 
of the outer layer of the second and third, and in some instances that 
of the first with the second, branchial folds (see Dermoids, Part VII, 
chap. i). As a matter of fact, most dermoids in this area are found 
in the subhyoid and submental regions between the skin and the floor 
of the mouth, where they are intimately connected with either the 
hyoid bone or the inferior maxilla. Most dermoids are separated from 
the floor of the mouth by the geniohyoid and the geniohyoglossus 
muscles (submental dermoids), although at times they are found located 
between the mucosa and the muscles mentioned {suhlingual dermoid). 

The submental dermoid presents, at first, below the chin, is covered 
with normal skin, and is elastic in consistence. As the tumor increases 
in size it elevates the floor of the mouth and then bears a resemblance 
to the sublingual form. 

The suhlingual dermoid, at first, is not palpable below the chin. As 
it grows it protrudes somewhat in the latter situation, but never to the 
extent that obtains in connection with its allied growth, i. e., the sub- 
mental form. When it reaches a certain size it cannot be differentiated 
from ranula (see above). 

The treatment consists in extirpation of the tumor. Irrespective of 
whether the dermoid is sublingual or submental, it is best removed from 
without, a maneuver which does not include entering the mouth (v. 
HippeP^). 

The rare teratoids of this region are extensively discussed by 
Niemczyk,^^ Renter,-^ Rolando,^" and Blanc. ^^ 

Solid Non-carcinomatous Tumors of the Tongue. — Lipomata of the 
mouth, and especially of the tongue, are not common. They 
usually spring from the submucosa or between the layers of muscles. 
They possess all the characteristics of a fatty tumor. Multiple lipoma 
of the tongue is reported by Malon^^ (see also bibliography of No. 12, 
which is very extensive). Extirpation of the growth presents no diffi- 
culties. 

Connective tissue tumors, fibromata, neurofibromata and fibromata 
with cartilaginous centers, are occasionally found in the tongue. It 
is not possible to recognize the exact character of these growths. How- 
ever, the clinical picture permits the conclusion that a benign process 
is being dealt with. 



THE SURGERY OF THE MOUTH 1675 

rapillomata of the mouth are usually pedunculated and are found 
on the uvula, the piUars of the fauces, and the dorsum of the tongue. 
As a rule they are about the size of a pea or a bean, but occasionally 
they grow to that of a hazel nut. Tumors of this sort are usually 
discovered during- an examination of the mouth made for another 
purpose. They are readily removed with the snare or scissors. 

Endothelioiiiafa of the mouth are exceedingly rare. They are most 
often found lodged in the palate close to the cheek, i. e., the arcus 
palatoglossus. Tumors of this sort present the clinical picture of a 
benign process, the character of which can be determined only by the 
microscope. 

Adenomata are usually situated at the base of the tongue. A tumor 
consisting of ihyroid tissue is also occasionally found in this location 
(Chamisso de Boncourt^^). The latter is, no doubt, the outcome of 
an atypical embryonic development. The removal of the growth is 
likel}' to be attended with great difficultJ^ In most instances it will be 
found necessary to proceed as in excision of the tongue for carcinoma 
(p. 1677). 

Sarcomata of the mouth possess the peculiarity that they often exist 
for years without causing disturbance and then suddenly rapidly 
increase in size. In these instances the tumor breaks down very early 
and presents the clinical picture of malignant disease. The exact 
character of the process can be determined only by the microscope. 
Of course, immediate removal of the growth and of as much of the 
contiguous normal tissue as is possible is imperative (Marion,** 
Melchior^^). 

Carcinoma of the Mouth. — Carcinoma in the mouth originates in 
three situations, the tongue, the cheek, and the mucosa of the floor 
of the mouth. The story of its causation would seem to be staged in 
an environment subject to chronic irritation, and to the ''tissue hyper- 
plasia" (precancerous stage of Huteheson) that goes with the latter. 
Of these processes, leukopla'kia is the most dominantly determining. 
(For statistics in this connection see v. Bergmann-Klittner.*®) The 
influence of lues upon the subsequent development of carcinoma of the 
tongue is not decided, yet the affirmative view is strongly supported 
(Butlin,^'' Warren,^^ Poirier*" and their bibliographies). 

Carcinoma of the tongue is practically always of the pavement epi- 
thelial type. Clinically the lesion may be divided into superficial and 
deep. The former begins in the surface epithelium, the latter, in the 
glands of the* mucosa. Primarily, it appears in the form of a nodule, 



1676 SURGERY OF THE FACE 

but this soou breaks down and an ulcer is formed, that is, carcinoma 
of the tongue may be said to present a tumor and an ulcer stage. The 
characteristics of both have been taken up in extensio in Part VI, 
chap. xvii. 

In carcinoma of the tongue the lymph nodes of the neck are involved 
early in the process. Tlie lymphatics of the entire tongue communi- 
cate very freely with one another, which accounts for the involvement 
of the lymph nodes of the neck on the side opposite to the tongue 
lesion (Kiittner^°). In the neck the carcinomatous infiltrate invades, 
primarily, the lymph nodes in the submaxillary and the submental 
regions (not the salivary glands) and those surrounding the internal 
jugular vein. In addition to this, the nodes at the tip of the parotid 
are promptly invaded. "When the process extends far beyond the 
neighborhood of the mouth, as it often does, the condition of the 
patient is nothing short of horrible. Strange to say, despite the rapid 
lymphatic extension of carcinoma of the tongue, the formation of 
metastases is comparatively rare. 

The diagnosis, as a rule, is not difficult, especially when ulceration 
is present. However, serious errors are frequently made. The most 
common of these is the assumption that the process is luetic in origin. 
Delay in differentiation from pressure ulceration, actinomycosis and 
tuberculous processes is also a common occurrence. When the dangers 
involved in allowing a carcinoma to remain are considered, the removal 
of a gumma of the tongue is not a reprehensible act. The accessibility 
of the process in question to the removal of a section for microscopical 
examination makes omission of this helpful measure unforgivable. In 
each instance a complete history of the behavior of the growth must 
be obtained, and when this, together with a careful study of its physi- 
cal characteristics and the microscopical findings, is anal^'zed, error in 
diagnosis will be avoided. There is no greater fallacy than to assume 
that a "positive "Wassermann" decides the character of a lingual ulcer- 
ative process. On the contrary, while a causative relationship between 
lues and carcinoma is not proved, chronic inflammatory processes 
unquestianaNy present a condition of affairs favorahle to the develop- 
ment of carcinoma. 

Carcinoma of the floor of the mouth presents a picture much like 
that of the tongue. It usuallj^ begins at the frenulum and extends 
along the body of the jaw, which it promptly invades. Once it attains 
certain dimensions, its subsequent behavior is in every regard similar 
to that of the tongue. 



THE yURGERY OF THE MOUTH 



1677 



Carcinuina of the mucosa of the check usually begins in the fold 
where this membrane is reflected over the ascending ramus of the jaw. 
The nodular stage is brief and ulceration follows rapidly. Carcinoma 
uf the mucosa of the hard palate soon invades the underlying bone. 
The process in these situations is similar in every respect to that 
involving the tongue. 

The special consideration with regard to the surgical treatment of 
carcinoma of the tongue, aside from extirpation of the growth, relates 

to removal of the lymph 
nodes from both sides of 
j;he neck by one of the so- 
called typical methods. 
Of these, that of Kiitt- 
jjgj.36 (pig_ 811) gives the 
widest exposure (for the 
other incisions see Krause- 
Hej-mann*"). The method 
permits of unilateral or 
bilateral ligature of the 
lingual and external 
carotid arteries. When 
it is necessary to section 
the jaw, this is post- 
poned for a few days to 
avoid extension of the 
infection into the neck 
wound from the mouth. 
Removal of the submaxil- 
lary salivary glands ren- 
FiG. 811. — Kuttner's Incisions foe Eemoval (Jers the deep lymph nodes 

OF THE CERVirAL LyMPH NODES IN CARCINOMA . . . . ^^^^ 

OF THE TONGUE. ^ ^^}^ situatiou morc 

accessible. 

The next step in the procedure is the radical removal of the tumor 
of the tongue. This may be accomplished under local anesthesia. 
When narcosis is employed, the patient is postured so that blood does 
not gain access to the air passages. In all extensive operations upon 
the tongue, lilaterol ligature of the lingual arteries is imperative. 
If the tissues contigl^ous to the tongue must be excised, unilateral or 
bilateral ligature of the external carotid artery is justified. The facial 
arteries are ligatcd when the submaxillary glands are removed. 




1678 



SURGERY OP THE FACE 



Butlin" practices prelimiuary laryn^otomy (70 cases) and administers 
narcosis in this way. This is a very useful measure. 

For the purpose of surgical efforts at relief, the tongue may be 
reached as follows: 

1. Through the mouth the greater part of the tongue may be 
removed with less difficulty than is generally believed. In 1908, 
Butlin^'^ reported 197 cases approached in this way. In none of these 
did he deem it necessary to divide the jaw, although in a few instances 
he excised a portion of the latter. For the purpose, the lower maxilla 
is widely separated from the upper by means of the Whitehead mouth 
gag (Fig. 774). The tongue is grasped with forceps or a traction 
suture is introduced. As the frenulum is divided the tongue is pro- 
gressively delivered from the 
oral cavity, and sectioned as 
far back as is possible. As 
the result of preliminary 
ligature of the lingual 
arteries (which must always 
be done), the bleeding is in- 
considerable, and is readily 
controlled by the usual 
means. As preliminary ex- 
clusion of the stump from 
the circulation favors gan- 
grene, it is not sutured. 

2. Section of the cheek 
gives little additional room 
and is employed only when the growth is small and located at the 
posterior portion of the edge of the tongue. The incision is made 
below the level of Stenson's duct. 

3. Submental {suprahyoid) or suhmaxillary incisions give oppor- 
tunity for the removal of a certain number of l,ymph nodes. A trans- 
verse incision is made just above the hyoid bone, and this is supple- 
mented by a second vertical section as far as the middle of the larynx. 
The muscles attached to the lower jaw are divided and the mucosa of 
the mouth is opened. Through this opening the tongue is delivered 
and amputated. The method is used only when the carcinoma is lim- 
ited to the anterior portion of the tongue and the floor of the mouth 
immediate!}' contiguous to it. 

Kocher's'^'^ iyicision begins at the middle of the lower jaw, extends 




Fig. 812. — Incision for Exposure of Base 
OF Tongue and Palate (v. Bergmann). 



THE SURGERY OF THE MOUTH 



1679 



to midway between the chin and hyoid bone, then parallels the body 
of the inferior maxilla to the anterior border of the sternomastoid 
uuisclo and thence backward and upward to the lobule of the ear. 
The flap is turned up and the l^^nph nodes of this region, together 
with the salivary maxillary gland, are removed, exposing the lingual 
artery, which is tied. Next, the mylohyoid muscle and the mucosa 
of the mouth is sectioned; the tongue is delivered through the wound 
and amputated. 

4. When the carcinoma involves the base of the tongue, or the 
palate and floor of the mouth, the lower jaw must he sectioned. Von 
BergmannV- modification of v. Langenbeck 's" method is largely 

practiced today. The cheek is 
divided transversely downward 
to the mucous membrane, from 
the angle of the mouth to the 
anterior edge of the masseter 
muscle, then downward at an 
acute angle, dividing all the 
soft parts, to the submaxillary 
region (Fig. 812). The jaw, 
corresponding to the latter in- 
cision, is freed of its soft parts 
and divided with a Gigli saw in 
an oblique direction (obliquely 
downward and forward) , which 
facilitates subsequent apposi- 
tion of the fragments. When 
the mucosa of the mouth is 
divided, the two ends of the 
separated bone can be held apart readily with retractors, and the sub- 
maxillary tissues conveniently extirpated. The approach to the oral 
cavity and to the lateral and posterior aspects of the pharynx is now 
satisfactory and as much of these structures may be removed as is 
necessary (Fig. 813). The method permits exposure of the facial and 
lingual arteries, which may be ligated before division. Contamination 
of the wound from the mouth is best guarded against by suturing the 
mucosa of the pharjTix to the lower angle of the skin wound, where it 
lies close to the larjnix. The secretions are thus directed into the 
dressing. The bone fragments are held in apposition with wire. 

5. Resection of a portion of the lower jaw, together with extirpation 




Fig. 813. — Exposure of Mouth and 
Pharynx through the v. Bergmann 
Incision Shown in Fig. 812, Hard 
Palate Being Chiseled Away. 



1680 SURGERY OF THE FACE 

of more or less of the oral contents, may be accomplished by the v, 
Bergmann method just described. By this method removal of the 
ramus of the inferior maxilla is easily accomplished. In totaling the 
cases of a number of surgeons, Kiittner^® estimates the mortality 
attendant upon extensive extirpation of carcinoma of the tongue at 
about 16.2 per cent. 

BIBLIOGRAPHY 

1. Griffith. Brit. Med. Jr., 1899, ii. 

2. PooLEY. Amer. Jr., 1872. 

3. GiROD. Gaz. des hopiteaux, 1900, No. 36. 

4. Welzel. v. Bruns' Beitr., 1910. 

5. Lengemann. v. Bruns' Beitr., 1910. 

6. Hunter. Brit. Med. Jr., 1904. 

7. Fede. Royal acad. med. chir. de Napoli, 1900. 

8. Pitts. Brit. Med. Jr., 1893. 

9. MuNCHHEiMER. Arch. f. Dermat. u. Syph. xl. 

10. FouRNiER. Des glossites tert., Paris, 1877. 

11. MoRiLLON. These de Paris, 1907, No. 382. 

12. V. Mikulicz und Kummel. Krank. d. Mundes, 1912. 

13. HiLDEBRAND. Deutsch. Chir., 1902, No. 13. 

14. Garel et Armand. Soe. med. Lyon, 1904. 

15. Illich. Die Klinik d. Aktinomyk., Vienna, 1894. 

16. Latte et Barret. Soe. med. des. hop. de Paris, 1908, ii. 

17. Levy. Zentrbl. f. Chir., 1913. 

18. GuTERBOCK. Deutsch. Zeitschr. f. Chir. xxii-xxviii. 

19. SiEGEL. Deutsch. med. Woch., 1893. 

20. Umbreit. Deutsch. Zeitschr. f . Chir., 1910, cv. 

21. Kuettner. v. Bnins* Beitr. xviii. 

22. Schmidt. Festschr. f. B. Schmidt, Jena, 1896. 

23. Neumann. Arch. f. klin. Chir., 1886, xxxiii. 

24. V. Recklinghausen. Virchow's Arch., 1881, Ixxxiv. 

25. V. HiPPEL. Arch. f. klin. Chir., 1897, Iv. 

26 MoRESTiN. Le Dentu-Delbet, Traite de Chir., 1898, vi. 

27. Debonelle. These de Paris, 1908. 

28. Niemczyk, Breslau, in Diss., 1899. 

29. Reuter. Fraenkel's Arch. f. LarjTig. u. Rhinol., 1905, xvii. 

30. Rolando. Sopra un tumor della lingua, Geneva, 1905. 

31. Blanc. Gaz. hebd., 1884. 

32. Malon. Tliese de Paris, 1884. 

33. Chamisso de Boncourt. v. Bruns' Beitr., 1897, xix. 

34. Marion. Rev. de chir., 1897. 

35. Melchior. Phila. Med. Jr., 1898, July. 

36. V. Bergmann-Kuttner. Handb. d. prakt. Chir., Stuttgart, 1913. i. 

37. BuTLiN. Brit. Med. Jr., 1898 : Monograph on 197 eases, London, 1908. 

38. Warren. Internat. Chir. Cong., Brussels, 1909. 

39. PoiRiER. Rev. de Chir., Paris, 1909. 

40. Krause-Heymann. Surg. Ops. ii, N. Y., 1917. 

41. Kocher. Cliir. Operationslehre, 1913. 

42. V. Bergmann. Deutsch. med. Woch., 1883, No. 42. 

43. V. Langenbeck. Verb. d. Deutsch. Gesell. f. Chir., 1879, viii. 



CHAPTER X 

SURGERY OF THE PHARYNX 

Malformations of the Pharynx. — Of the malformations of the 
pharj'iix, few possess surgical interest. Teratoma is occasionally found 
in this situation. Epignathus, because of the interference with 
breathing- which it causes, soon destroj^s the host. However in several 
instances the mass has been successfully removed. 

Diverticula, cysts, and fistulae are due to errors in development of 
the branchial clefts. Diverticula of the upper branchial cleft are 
located near the eustachian tube; those of the second, correspond to 
a dilated fossa of Rosenmiiller, or they may be of sufficient size to 
extend to the skin. Diverticula on the ventral side of the second 
branchial cleft, from which the tonsillar fossa is derived, are the most 
common, although not so common as are fistulae in this situation. 
Diverticula in this region are likely to be very extensive, encroach- 
ing upon the anterior triangle of the neck between the stemomastoid 
and the trachea. Diverticula of the third branchial cleft are located 
above the superior laryngeal nerve and protrude between the hyoid 
bone and the thyroid cartilage. 

Conge7iital cysts appear in all locations in which diverticula are 
found. To this class belongs the cyst found in the sinus pyriformis, 
and probably also those found in front of the epiglottis and in the 
glossopharyngeal ligament. 

Branchiogenous cysts of this sort are at times responsible for a 
peculiar metallic quality of the voice of the host, and are very likely 
to interfere with deglutition. They should be extirpated by one of 
the external methods discussed farther on (Wheeler,^ Schneider,^ 
KiimmeP). 

Inflammatory Diseases. — Inflammatory diseases of the pharynx and 
of the tonsils, especially diphtheria, are taken up in the general part 
of this work. 

Phlegmonous Tonsillitis and Peritonsillitis. — Phlegmonous in- 
flammation of the tonsil and the surrounding tissues furnishes a clini- 

1681 



1682 SURGERY OF THE FACE 

cal picture of some surgical importance. Suppurative processes in the 
tonsil always develop in connection with peritonsillar phlegmon, which 
renders establishment of the original seat of the infection uncertain. 
The chronic form of tonsillar abscess (so-called) corresponds to a 
dilated tonsillar crypt filled with purulent secretion and detritus. 

Peritonsillar phlegmon is characterized by an inflammatory swelling 
of the capsule of the tonsil, which forces apart the pillars of the fauces. 
The inflammatory infiltrate in the peritonsillar tissue is dominantly 
manifest at the upper aspect of the palate, where the Ij^mphatics are 
most abundant. In severe cases the infiltrate extends to the lymph 
nodes at the angle of the jaw and into the retropharyngeal connective 
tissue. 

The onset of a phlegmo7ious tonsillitis is usually heralded by a chill 
and a sharp rise of temperature, which is associated with an acute in- 
fectious process. This is soon followed by d^ysphagia and more or less 
localized pain at the seat of the infection. If the process persists for 
three or four daj's, the uvula is also infiltrated, and in not a few cases 
invasion of the epiglottis is responsible for serious interference with 
respiration, so that tracheotomj^ becomes necessary. 

Sponfcmeous rupture of the ahscess occurs into the supratonsillar 
fossa, occasionally through the anterior, and, in rare instances, through 
the posterior pillar of the fauces. Death may be caused by the sudden 
rupture of an abscess of this sort and the discharge of pus into the 
larynx. Fatal results have been the ouctome of ulceration into the 
internal carotid artery, extension of the infiammation into the medias- 
tinum, extension of a secondary suppurative phlebitis into the jugular 
vein, and of a general infection. 

The di-CKjnosis is not difficult. However, unless the throat is ex- 
amined, the condition Mdll escape recognition. As opening the mouth 
is difficult, the surgeon must depend upon the palpating finger in this 
connection. Discovery of the infiltrate, together with the picture of 
an acute infectious process, should make the diagnosis. Difficulties 
arise only in the milder forms of the disease, when the question of the 
presence of a new growth, complicated by a local inflammatory re- 
action comes up. In these instances aspiration of the area of thicken- 
ing should be resorted to. 

The treatment consists in incising the inflamed area. This must 
not be too long delayed. In making the incision, the rule laid down by 
Chiari* may be followed. The knife is entered at a point midway 
between the base of the uvula and the posterior molar tooth, where 



SURGERY OF THE PHARYNX 



1683 



is ma}' be advanced to a depth of from 1 to 2 cm. without danger. It 
is advantageous to increase the size of the opening with the Mayo 
scissors (Fig. 510). Local anesthesia is not desirable. As phlegmonous 
peritonsillitis is an exhausting disea.se, nourishing the patient through 
a nasal catheter is a valuable mea.sure. After the process has sub- 
sided, the ({uestion of removal of the tonsils must be taken up. 

The Retropharyngeal Abscess. — Abscess behind the posterior wall 
of the pharynx results from gravitatimi of an infection of the cervical 
vertebrae, of the base of the skull, or from extension of an infection by 
means of the lymphatics situated in its posterior wall. The Ij^mphatics 
in this situation are very numerous and drain the nose, its accessory 

sinuses, the posterior wall of the 



pharj'nx and the pharyngeal 
tonsils, any of which may be 
the port of entrance of the 
causative excitants. 

The clinical picture of retro- 
phar\Tigeal abscess is that of a 
general septic infection, to- 
gether with disturbances of 
deglutition a n d respiration. 
The latter is caused by me- 
chanical obstruction and by in- 
fiammatorj' edema of the tis- 
sues. Both of these may reach 
extensive proportions and often 
threaten the life of the patient. 
Rupture of the abscess involves 
the danger of death by strangu- 
lation. This is especially true in childhen in whom the lesion is most 
frequently seen. 

The diagnosis is not made as often as it should be. It rests mostly 
upon the examination which reveals the presence of a mass, usually 
covered with almost normal mucosa, causing the posterior phar\-ngeal 
wall to bulge. Palpation elicits fluctuation which, together with the 
general sj-mptoms of infection, should make the diagnosis certain. 

The treatment consists in opening the abscess in the median line 
with the patient's head lowered. AYhen the abscess is tuberculous (in 
connection with spondylitis) it is aspirated and injected with iodoform 
emulsion. 




Fig. 814. — Peritonsillar Abscess. 
Showing point where liberating incision 
should be made. 



1684 SURGERY OF THE FACE 

Hypertrophy op the Pharyngeal Tonsil. — Hypertrophy of the 
pharyngeal tonsil (erroneously designated as adenoid vegetation), in 
children up to twenty years of age, is the most frequent cause of in- 
terference with nasal respiration and of acute and chronic middle ear 
infections; it is, therefore, a lesion of great surgical importance. 

While the etiology of hypertrophy of the pharyngeal tonsil is un- 
known, it may be definitely stated that the lesion is not tuberculous, 
nor does it constitute a port of entrance for this disease. 

Objectively, the presence of the affection may be established by an- 
terior or posterior rhinoscopy or by palpation. Obstruction to nasal 
breathing is the most striking of the subjective symptoms. To this is 
added mouth breathing, a stupid expression of countenance, and dis- 
turbances due to irritation of the air passages. If relief is not af- 
forded before the second teeth appear, permanent deformation of the 
maxillae often occurs. Interference with the normal processes of 
life caused by obstruction to nasal respiration is held responsible for 
disturbances in the development of the thorax and abdomen. 

The treatment of hypertrophy of the pharyngeal tonsil is limited to 
its operative removal. A large number of instruments have been de- 
vised for the purpose, of which the Beckmann modification of the 
Gottstein curette is perhaps most frequently used. The instrument is 
inserted behind the palate until it rests against the posterior edge of 
the septum ; the cutting edge of the curette is rotated around an axis 
corresponding to the size of the epipharjoix and the tonsil is readily 
detached in toto. The separated tonsil falls into the lower pharynx 
and is expelled. In the instances in which the patient " swallows the 
mass," the maneuver probably has not succeeded. The extent of the 
bleeding varies widely. Fatal hemorrhage has been found to be asso- 
ciated with hemophilia. The wound heals in from eight to fourteen 
days. Because of the danger of forcing infection into the middle 
ear, the pharynx should not be lavaged. Narcosis is essential; local 
anesthesia cannot be accomplished in this situation. 

Hypertrophy op the Palatine Tonsil. — The etiology of hyper- 
trophy of the palantine tonsil is no more clearly understood than is 
that of the pharyngeal tonsil. The organ is often the seat of inflam- 
matory foci which are regarded as tuberculous in character. There is 
no doubt that the tonsil is often the port of entrance of general in- 
fections and that this occurs more frequently when these organs are 
the seat of hypertrophic changes. 

The enlargement of the tonsil is a familiar spectacle and varies 



SURGERY OF THE PHARYNX 1685 

greatly iu extent. The organ protrudes into the arch of the palate, 
unless it is adherent to its bed between the pillars of the fauces — a 
common occurrence. Close scrutiny reveals the enlarged tonsil, either 
smooth or irregularly excavated. The excavations are flecked with 
yellowish plugs of detritus. In children they are soft, in adults, hard 
in consistence. The extent to which the tonsil extends downward 
can be determined only with the mirror. This should alwa3^s be ascer- 
tained, especially as the dependent portion of the organ is frequently 
responsible for recurrent attacks of acute tonsillitis. 

The clinical picture of hypertrophical tonsils is exceedingly variable. 
Not a few of the disturbances ascribed to the palatal tonsils are really 
due to the presence of a coexisting enlarged pharyngeal tonsil. Simul- 
taneous involvement of these organs is the rule. The chief symptom 
of enlargement of the palatal tonsils relates to interference with de- 
glutition. Pain is present only during an acute inflammation. How- 
ever, a feeling of discomfort and cough are likely to be present be- 
tween the attacks. Very large tonsils interfere with breathing, es- 
pecially at night, when they cause the patient to snore. The most 
common and distressing complication of hypertrophy of the tonsils 
consists in frequent acute inflammatory exacerhations of the subacute 
or chronic process. Regression of the affection may occur aftei 
puberty. This, however, is not constant. A certain degree of restitu- 
tion to the normal at times follows spontaneous or therapeutic evacu- 
ation of the tonsillar crypts and the healing of a peritonsillar abscess. 

In the treatment, tonsillotomy, slitting of the tonsillar crypts and 
tonsillectomy are taken into consideration. 

Tonsillotomy (amputation of the tonsil) consists in removal of the 
protruding portion of the organ. As the infected crypts extend to 
the capsule, the operation attains the object only when the amputa- 
tion includes removal of the intrapalatal portion of the tonsil. In 
order to accomplish extracapsular removal of the tonsil with the ton- 
sillotome, the organ must be delivered from the fauces, grasped with 
hooked forceps, drawn toward the median line and sectioned at its 
base. As the tonsil is often adherent to the pillars of the fauces, it 
must first be released ; this is readily accomplished by a specially 
constructed hooked knife. Excision of a sector of the fauces increases 
the danger of secondary bleeding, which is often followed by impair- 
ment of the singing voice. At the present time the tonsil is enucleated 
as follows : The patient is narcotized, the narcosis being maintained 
by spraying ether vapor into the mouth ; a suction apparatus keeps 



1686 SURGERY OF THE FACE 

the operative field clear of blood j the tonsil is grasped and separated 
from the pillars of the fauces as stated above; a snare (cold) is passed 
over the forceps and carried around the tonsil and the section made 
close to the base of the latter ; the few bleeding points are clamped 
for a few minutes, and the same procedure is executed on the opposite 
side. The pharyngeal tonsil is removed at the same sitting. 

Slitting of the tonsillar crypts is a conservative procedure used in 
cases of moderate hypertrophy and slight general disturbances. The 
tonsil is delivered into the median line, as stated above ; the crypts are 
opened with a long, slender knife and emptied of detritus. The pro- 
cedure is not much practiced at this time. Removal of the tonsil with 
the finger is also rarely performed. 

Hemorrhage following tonsillectomy is usually inconsiderable and 
is almost always controllable in the manner stated. The "bugbear" 
of injury to the internal carotid may be dismissed with this mention. 
Uncontrollable bleeding occurs in hemophiliacs, although it has also 
happened from other causes (diabetes, nephritis, etc.). In these 
instances, ligature of the external carotid artery is justified. 

After the operation the patient is kept m bed for twenty-four hours 
and is nourished with liquid food. The fibrinous exudate which 
covers the wound surfaces must not be disturbed. 

Lues, Tuberculosis, Lepra, Scleroma, and Glanders of the Pharynx.— 
Of the inflammatory processes of the pharynx caused by specific 
excitants, lues is hij far the most frequent. 

The primary lesion of lues occurred on the tonsil 504 times in 10,265 
cases of extragenital infection collected by Mimchheimer.^ The 
infection may be conveyed by coitus praeter naturam or by contam- 
inated food, table implements, etc. As the lesion is attended with a 
severe local reaction and the lymphatic glands are greatly involved, 
the process is likely to be mistaken for malignant disease, especially 
when there is much sloughing of tissue in the pharynx. The diagnosis 
is not difficult, if lues is thought of. The spirochete is often present 
and an injection of salvarsan is followed by healing with astonishing 
rapidity. The simultaneous presence of plaques miiqueuses, especially 
when these show a tendency to ulcerate, is of great diagnostic 
assistance. 

Gummatous lesions are also frequently located in the pharynx and 
are usually situated on its posterior wall and on the soft palate. The 
gummata are often multiple, break down early, and in healing cause 
grave distortions of the tissues. When the lesion is located in the 



SURGERY OF THE PHARYNX 1687 

ei)ij)haiynx, it is likely to escape notice unless disturbances in degulti- 
tiou cause the surgeon to make a posterior rliiuological examination. 

Tuberculosis of the pharynx appears in its lupous form or as dm 
ordinary infiltration and ulceration. The character of lesions of this 
sort affecting the tonsil has been revealed by the microscope (Seiffert"). 

The lupous form occurs by extension from the lip by means of the 
mucosa of the mouth and frequently involves the larynx. It presents 
a picture very similar to the process on the face and, like the latter, 
shows a tendency to heal. In most cases, unless the larynx is involved, 
the patient does not suffer much inconvenience. In advanced cases 
deglutition is accomplished with difficulty. The outcome depends 
upon the laryngeal and pulmonary involvement. The treatment is 
similar to that employed in efforts to relieve tuberculosis situated 
elsewhere in the body, i. e., curettement or excision of the local lesion 
and the use of general sustaining nourishment, etc. The local appli- 
cation of iodoform paste seems to be of benefit. 

The infiltrating form of pharyngeal tuberculosis soon ulcerates. It 
most often invades the soft palate, where it presents the typical pic- 
ture of a mucous membrane lesion of this class. If the ulcer destroys 
large areas of the palate, it is not easily differentiated from a luetic 
lesion. Microscopical examination of an extirpated section is likely 
to remove any doubt in this connection. It must be remembered that 
pulmonary tuberculosis and a luetic pharyngeal lesion may coexist. 
The treatment is similar to that of the lupous form of the disease. 

Lepra of the pharynx probably occurs more frequently than is 
generally believed. The process is at first nodular in character which 
soon leads to cicatrical shrinkage. See Part II, chap. xxiv. See also 
Michelson,^ Bergengriin.^ 

Scleroma of the pharynx appears as a part of the same process in 
the nose (Part II, chap, xxvi; Pieniazek"). 

For glanders see Part II, chap, xviii. 

Injuries and Foreign Bodies in the Pharynx. — Of the injuries of the 
pharynx, those caused by burns and chemical cauterization (attempted 
suicide) .are of especial interest because of the distortions and stenosis 
which follow repair. When the pharynx is incised from without 
(also frequently in connection with attempted suicide), the develop- 
ment of distressing fistula can only be prevented by exact suture of 
the divided mucosa and its inversion by means of a second layer of 
sutures introduced into the pharyngeal wall. The outer wound must 
be drained in all instances. 



1688 SURGERY OF THE FACE 

Foreign todies in the pharynx are usually bone fragments, fish 
bones, and needles, which are introduced with articles of diet and are 
most frequently located in the sinus pyriformis or the deeper portion 
of the pharynx. They are located with the mirror or the palpating 
finger. The Rontgenographic finding is likely to be of great assist- 
ance. If the substance is deeply situated, the esophagoscope may have 
to be used to determme its exact location. Foreign bodies in the sinus 
pyriformis provoke edema of the aryteno-epiglottic fold, thus endan- 
gering the patient's life from strangulation. In these eases the 
prompt performance of a tracheotom}^ is a life saving measure. This 
permits careful exploration of the seat of the obstruction, and when 
suppuration occurs incision of the inflamed area is very likely to be 
followed by expulsion of the offending agent. In a certain number 
of cases the abscess gravitates to the neck and must be opened in this 
situation. The foreign body may then be expelled through the 
external wound. 

Stenoses and Distortions of the Pharynx. — Most stenoses of the 
pharynx are the result of a healed luetic lesion, although a few follow 
chemical cauterization. 

Cicatricial coalescence at the junction of the mesopharynx and epi- 
pharynx is due to adherence of the soft palate to the wall of the 
phar\Tix. Complete atresia of the nasopharynx is rare; usually, a 
small opening persists. Patients afflicted in this way are mouth 
breathers and have no sense of smell. In the incomplete form, fluids 
are likely to flow from the mouth into the nose. 

Cicatricial stenosis at the site where the mesopharynx communicates 
with the mouth and the hypopharynx is always partial, although 
deglutition is more or less interfered with and the voice is also affected, 
especially w^hen the base of the tongue is involved in the process. In 
not a few instances, cicatricial bands are located at the upper end of 
the larynx. 

The treatment of this class of cases is not very satisfactory. Even 
during the stage of healing, it is hardly possible to prevent the forma- 
tion of the strictures. When cicatrization is completed, efforts at 
reestablishment of a physiologically sufficient opening may be made. 
Gradual dilatation is practiced in connection with obstruction at the 
hypopharynx. It may be followed by severe reaction and is, therefore, 
usually preceded by tracheotomy. Division of the scar tissue is fol- 
lowed by return of the obstruction, unless this is supplemented by per- 



SURGERY OF THE PHARYNX 



1689 



sistent and prolonged use of the bougie. Gastrostomy may be necessary 
(v. Eicken^"). 

Benign Tumors of the Pharynx. — So-called typical nasopharyngeal 
])()lypi possess considerable surgical importance. Histologically they 
are true fibromata. Despite the fact that at times they break through 
the surrounding bony structures they never form metastases. The 
vascularit}' of these growths varies widely. Some are nourished by 
vessels the size of the radial arter}-. However, most of them possess 

larger or smaller vascu- 
lar plexuses, some of 
which present a caver- 
nous form. 

The tumors spring 
from the base of the 
skull ; usually from one 
of the bony processes. 
Their area of origin is 
in the "fibrocartilago 
basilaris, " which is 
covered with perios- 
teum and extends from 
the posterior edge of 
the nasal septum, along 
both wings of the 
sphenoid bone and the 
pterygoid fossa, and 
then turns downward 
and backward to include the phar^Tigobasilar fascia, the cartilages of 
the eustachian tubes, and the petro-occipital sjmdesmosis. The tumors 
are covered with mucous membrane, except when this has been 
destroyed by trauma and consequent ulceration. The latter frequently 
gives rise to bleeding, though this is not often menacing. 

Obstruction to nasal breathing is the first indication of the presence 
of the tumor. This is soon followed by a more or less profuse mucous 
or purulent discharge. The pernicious effect of the growth is the 
result of its rapid increase in size. At first the tumor grows into the 
epipharj'nx and its neighboring nasal cavities on one side and then into 
those of the other. From the nose it gains access to the sphenoid, max- 
illary, frontal and ethmoid sinuses, all of which it ultimately fills up, 
breaking through their walls, and, in not a few instances, extends into 




Fig. 815. — Sagittal Section of a Nasophabyngkal 
Polypus. 



1690 



SUKGERY OF THE FACE 



the cranial cavity. From the sphenoid sinuses the process often in- 
vades the orbital cavities, though this is more likely to occur in connec- 
tion with sarcomata. During all of these extensions, the character 
of the tumor remains benign, and it maj' be lifted from the respective 
canity of origin without difficulty. It is a singular fact that in a 
certain number of instances the tumor undergoes considerable atrophy 
after pubertj' or after incomplete extirpation. 

The clinical findings are fairly uniform. As a rule the mass fills 
the entire nasopharj-nx. Its upper and anterior surface is usually 
smooth, while the portion obtrud- 
ing into the pharjTix is likely to be 
ulcerated. Its dimensions may, in 
a measure, be determined by visual 
examination and by palpation ; fre- 
quenth' it permits of some motilitj*. 
Its insertion is not easy to de- 
termine, so that m making an 
operative effort at relief one must 
be content with the empirical 
assumption that the tumor has 
sprung from the under surface of 
the sphenoid bone or the basilar 
process. 

The disiorticyiis caused by the 
growth are likely to be extensive. 
The nasal process lifts the wing of 
the nose, the nasal bones are sepa- 
rated and exophthalmos is often 
marked. Invasion of the maxillary 
sinus is characterized by protru- 
sions of the cheek, and the temporal 

fossa is often obliterated. These deformations, together with the open 
mouth, present a characteristic picture (Fig. 816). 

The dijferenii/il diagnosis takes into account the ordinary nasal 
poh-pi which protrude into the epiphar^Tix. These are bluish or gray 
in color, while fibromata are dark red. On palpation, fibromata are 
hard, polypi soft, in consistence. Bleeding and extension into the 
contiguous cavities are essentially the p^i^^lege of fibromata. How- 
ever, the latter characteristics are also possessed by sarcomata. Dif- 
ferentiation between sarcoma and fibroma is, unfortunately, not easy. 




Fig. 816. — Eetromaxillaey 
Fibroma. 



SURGERY OF THE PHARYNX 1U91 

The fact that a fibroma, even when invaginated in a bony sinus, is 
somewhat movable, is helpful. A neoplasm protruding from the retro- 
pharyngeal tissues must also be taken into accoujit. Chondromata 
and teratomata in this situation are rare; the former is distinguished 
by its hard consistence. 

The prognosis, despite the benign character of the growth, is not 
good. An unfavorable outcome results from bleeding, invasion of the 
cranium, and meningitis. Very large tumors interfere with degluti- 
tion and respiration. 

The treatment, in small tumors, consists in their destruction b}^ the 
galvanocautery. Extirpation by the direct route may be accomplished 
by means of the snare. The manipulation is not easy and requires 
considerable skill in rhinological toehnic. Avulsion of the grow^th in 
toto W'ith forceps introduced through the mouth has often been suc- 
cessful ; the measure is attended with considerable bleeding. Exten- 
sive growths are best attacked by preliminary exposure of the pharynx 
(p. 1694). 

Other henign tumors of the epipharynx and the mesopharynx are 
similar in character to those described in the general part of this work 
(see Tumors, Part VI). 

Teratomata occasionally spring from the dome of the pharynx. 
They xsivj greatly in size and are distinguished by their epidermal 
covering, which usually possesses some hair (the hairy poh'pi of 
Reuter^^). Extirpation of the tumor through the mouth presents no 
difficulties. 

Pedunculated fibromata occasionally arise from the posterior rim of 
the choanae and from the pillars of the fauces, and hang down into the 
pharjTix. They bear considerable resemblance to polypi and are 
treated as such. So-called lymphadenoid polypi are also found in 
this situation. These are attributed to displaced portions of the 
tonsillar anlage. Another form of tumor of similar firm, but somewhat 
coarser, structure found in this region is regarded as a congenital 
dermoid. 

Enchondromata and osteomata springing from the basilar process 
have already been alluded to in connection with na-sopharj-ngeal 
fibromata. 

Of the tumors composed of vessels occurring in the mesopharjTix 
cavernous angiomata are the most common, although occasionally 
lymphangiomata also make their appearance in this situation. The 
angiomata do not attract attention unless hemorrhage suddenly de- 



1692 SURGERY OF THE FACE . 

velops. In view of the great vascularity of the growths, they are best 
attacked with the galvanocautery. 

Of the benign tumors occurring in the mesopharynx, papillomata 
are the most frequent. These are warty in structure and are covered 
with an epidermoid layer. Disturbances are caused only when the 
tumors possess long pedicles and provoke irritation of the air pas- 
sages (tickling, gagging). They are readily ablated with the scissors. 

Of the cystic tumors, small retention cysts of the glands of the soft 
palate are the most frequent. 

Mixed tumors of the pharynx occupy a position between benign and 
malignant growths. They lie between the pillars of the soft palate, 
and at times send a prolongation through the pharyngeal fascia, which 
communicates with a similar, larger tumor of the parotid gland (hour- 
glass parotidopalatal tumors). Usually these tumors are at first 
benign, but they reach gigantic proportions and cause serious pressure 
disturbances. As they increase in size, pressure ulceration occurs, 
which is attended with a picture not unlike that of a brokendown 
gumma. The peculiarity of the growth lies in the fact that it may 
remain quiescent for years and then suddenly develop all the char- 
acteristics of a malignant process which exhibits the histological picture 
of a round cell sarcoma. 

As long as the process remains benign, the tumor may be shelled 
out of its bed with ease. The smaller growths may be removed through 
the mouth, the larger ones must be extirpated by the external route 
(p. 1691). 

Extrapharyngeal tumors which encroach upon the pharynx arise 
from the base of the tongue and the retrovisceral tissues. Of the 
tumors of the base of the tongue, large cysts are very likely to pro- 
trude into the pharynx. They probably spring from rests of the 
thyroglossal duct. In addition to this, solid tumors, arising from the 
same source, consist of accessory thyroid glands (struma). Extravis- 
ceral strumata arise from the upper pole of the thyroid body and 
encroach upon the pharjTigeal lumen. Retropharyngeal tumors 
spring from the connective tissue of the retrovisceral space. These 
make their appearance in the varied forms of growths arising in con- 
nective tissue, mostly, however, as fibromata and enchondromata orig- 
inating from the periosteum of the vertebral column. Their extirpa- 
tion must be accomplished by the external route. 

Sarcomata of the Pharynx. — Excluding typical nasopharyngeal 
fibromata, sometimes regarded as malignant, sarcomata in this region 



SURGERY OF THE PHARYNX 1693 

are rare. The diagnosis is very uncertain; even the microscope does 
not furnish the necessary information in this connection. Lympho- 
sarcoma is the most common form in which this class of growth is 
presented. They spring from the follicles of the pharynx, palate, and 
lingual tonsil. At first the process has the appearance of a simple 
hypertrophy, which is usually covered with a white, flecked deposit. 
As the disease progresses, the neighboring mucosa is infiltrated, until 
the entire epipharynx and mesopharynx are filled by the tumor. The 
regional lymph nodes are invaded early in the progress of the disease 
and may be the first evidence of the process. Later, disturbances of 
deglutition and respiration dominate the picture, and finally the intra- 
pharyngeal growth breaks down. Sarcomata of this variety are not 
always readil}'- distinguished from lymphomata, pseudoleukemia and 
leukemia. 

The other forms of sarcoma develop in the tonsil and usually are of 
the round cell variety. A number of small sarcomatous tumors often 
invade the pharynx from the upper portion of the larynx, and pre- 
vertebral sarcomata also encroach upon the pharynx (Bergeat^^). 
Clinically, the former class of sarcomata cannot be differentiated from 
benign fibromata. They may be extirpated from the mouth. Sarco- 
mata of the tonsil may be extirpated by the external route (p. 1679), 
The larger lymphosarcomata are not susceptible to operative measures 
of relief. 

Carcinoma of the Epipharynx, Mesopharynx, and Hypopharynx. — 
Carcinoma most often invades the pharynx from the tonsil. The 
process is usually rapid, extending first along the retromaxillary lymph 
nodes and then into those situated along the carotid sheath. The 
glandular involvement often attracts attention before the carcinoma 
in the tonsil or pharynx is recognized. The growth is usually of the 
glandular type, rarely of the squamous. The latter occurs in the 
hypopharynx in connection with carcinoma of the larynx. 

The clinical course and symptomatology of pharyngeal carcinoma 
varies with its location. 

Nasopharyngeal carcinoma presents a picture similar to that of 
sarcoma in this situation (see above). 

Oropharyngeal carcinoma is usually heralded by painful deglutition. 
This is soon followed by swelling of the cervical glands, which prompts 
the surgeon to examine the throat, thus uncovering the process in the 
pharynx. Occasionally, the pharyngeal (or tonsillar) growth is not 
ulcerated, simply presenting a firm, globular swelling (nodular stage 



1694 



SURGERY OF THE FACE 



of carcinoma; which seems to force the tonsil into the pharynx. At 
this time the process is very likely to be mistaken for a gumma. ^Yhen 
ulceration is established, the excavation always has a hard edge (see 
Carcinoma of Mucous Membranes, p. 1273). 

The lesion must be differentiated from tuberculosis (including 
lupus), actinomycosis, lues, and simple mucous ulcer. The determin- 
ing factors are taken up in discussing carcinomata of the tongue 
(p. 1675). 

Carcinoma of the kypopharynx is usually a part of laryngeal carci- 
noma. However, occasionally the disease appears primarily in this 
situation in the form of an annular zone of thickening, which soon 
ulcerates and shows a tendency to obstruct the lumen of the lower 
pharynx. Extension 
to the sinus pyri- 
f ormis, the a r c u s 
p a 1 a t o pharyngeus 
and the tongue is the 
rule. 

Pain and difficulty 
in deglutition are the 
chief symptom!^ of 
carcinoma of the 
hypopharj-nx. This 
leads to examination 
and recognition of 
the lesion. The 
esophageal sound 
must be used with 
care. Direct examination of the hypopharjTix with the esophagoscope 
will lead to a prompt diagnosis. 

Operative Exposure of the Pharynx. — The principle of all operative 
measures directed toward removal of growths of the pharynx involves 
preliminary wide exposure of this part. This applies to benign as 
well as malignant processes. 

Temporary resection of the alveolar processes, together with the 
hard palate, has already been taken up (p. 1679). The operation gives 
ample access to the posterior nares, but not to the epipharynx. 

Osteoplastic resection of the upper jaw gives a wide exposure of the 
nasopharjTix. The technic of the procedure is similar to that prac- 
ticed in connection with incision of the superior maxilla (p. 1646), 




Fig. 817. 



Exposure of the Xasophabynx 
(v. Langenbeckj. 



SURGEKY OF THE PHARYNX 



1695 



except that it is carried out on both sides and the cheek flaps are not 
separated from the bone. The bone and soft parts of both halves of 
the upper jaw are turned back on each side of the face (Fig. 817), 
and the nose, after division of the nasal bones and septum, is turned 
upward. Preliminaiy ligature of both external carotid arteries and 
tracheotomy are generally practiced. 

The removal of tumors from the mesopharrjnx and the tonsil is best 
accomplished by lateral section of the inferior maxilla in the manner 
described in connection with carcinoma of the tongue. While carci- 



nusc 




,SuP. LARYNGEAL 

ntRve. 




Fig. 818. — Traxs^'erse Subhyoid Phakyxgotomy. 



noma of the tonsil has been removed through the mouth, this is not 
generally regarded as sufficiently thorough to give reasonable security 
against return of the disease. Of course, the lymph nodes in the neck 
must be removed at the same time (Kronlein,^^ Citelli,^* Krause- 
He^Tnann^^). 

Of the operations employed for the purpose of gaining access to the 
hypopharynx, transverse subhyoid or lateral pharyngotomy gives 
ample space. 

Tumors of the epiglottis are easily enucleated by transverse sub- 



1696 SURGERY OF THE FACE 

hyoid pnaryngotomy. The incision is made immediately over the 
hyoid bone and extends from one of its ends to the other. The hyoid 
artery and vein are tied and, after the bone is exposed, the insertions 
of the sternohyoid, omohyoid and th^Tohyoid muscles are divided. 
The superior larj-ngeal ner^-e is avoided. Section of the thyrohyoid 
membrane exposes the upper portion of the hypopharjoix (Fig. 818). 

For removal of tumors in the lower hj-popharynx, transverse, com- 
bined with lateral, subhyoid pharyngotomy becomes necessary. 
Lateral pharyngotomy may .be practiced alone. See Brj^ant.^'^ The 
incision begins in the middle of the hyoid bone, and extends along 
this bone to the anterior border of the sternomastoid muscle, where it 
curves upward opposite to the angle of the jaw. The sternohj'oid, 
omohyoid, and thyrohyoid muscles are separated from the lower edge 
of the bone. The submaxillary glands and the lymph nodes are re- 
moved and the thyrohyoid membrane and the muco?a are opened in a 
transverse direction. When the hyoid bone is lifted with a blunt 
hook, the entire hypopharjaix and its mergence into the esophagus is 
laid bare, 

In order to preserve normal deglutition, the connection between the 
larynx and the h^^oid bone should not be abolished. This is less dis- 
turbed by lateral than by subhyoid phar^Tigotomy. 

When the glands of the retromaxillary and submaxillary regions are 
involved and section of the lower jaw is necessary, this. may be readily 
accomplished by the method discussed in connection with operations 
for carcinoma of the tongue (p. 1677). 

For the relief of extensive laryngopharyngeal carcinoma the retro- 
th}Toid or retrolaryngeal methods of Quenu-Sebileau^^ or of Rasu- 
mowski^^ may be eraplo^'cd. An incision is made along the anterior 
border of the sternomastoid, and the pharjTix invaded by careful dis- 
section of the muscles, vessels and nerves. The technic of the pro- 
cedure is largely a question of the surgeon's knowledge of anatomy, 
which it is impossible to supplement here (see Krause-Hej^mann^^). 
Gluck's^^ simultaneous excision of the larynx and pharynx is discussed 
elsewhere (p. 1754). 

BIBLIOGRAPHY 

1. Wheeler. Dublin Jr. of Med. Sci.. 1886. 

2. ScHNEmER. Liefg. No. 7, Schwalbe's Morphol der Missbild., Jena, 1912. 

3. KuMMEL, in Handb. d. prakt. Chir. i, Stuttgart, 1913. 

4. Chiari. Wien. med. Woch., 1889. 



SURGERY OF THE PHARYNX 1697 

5. MiJNCHHEiMEit. Arch. f. Derm. u. Syph. xl. 

6. Seipfekt, in Heymann's llandb. d. Laryiigol. u. Rhino, ii. 

7. MiciiELSON, in Heymann's llandb. d. Larynj2:ol. u. Rhino, ii. 

8. Bkkgenguux, in Heymann's llandb. d. Laryngol. u. Rliino. ii. 

9. PiENiAZEK, in Heymann's Handb. d. Laryngol. u. Rhino, ii. 

10. V, EiCKEN. Verb. d. Vereins deutsch. Laryngol., 1910. 

11. Reuter. Fraenkel's Arch. f. Laryngol., etc., ii. 

12. Bergeat. Monatschr. f. Ohrenheilk, xxix. 

13. Kronlein. v. Bruns' Beitr. xjvii. 

14. Citelli. Fraenkel's Arch. f. Laryngol. xvii, 

15. Krause-Heymann. Surg. Ops. ii, N. Y., 1917. 

16. Bryant. N. Y. Med. Jr., 1891, ii, iv. 

17. Quenu-Sebileau. Rev. de Cliir., 1904. 

18. Rasumowski. Russ. chir. Arch., 1906, ii. 

19. Gluck. Monatschr. f. Ohrenheilk, 1904, Nos. 3-4. 



PART XII 
SURGERY OF THE NECK 



CHAPTER I 

MALFOEMATIONS OP THE NECK 

Congenital Fistulse and Cysts of the Neck. — Congenital fistulee are 
divided into median and lateral. 

The median fistula is the result of an eversion of that portion of the 
epithelial laj^er of the floor of the mouth which is concerned in the 
formation of the middle lobe of the thj^roid gland. In fetal life, as 
the thyroid body sinks downward, the canal leading from this gland to 
the root of the tongue (foramen cecum) is not obliterated. This 
canal, or duct (thyroglossal duct), runs from the foramen cecum to 
the hyoid bone. The fistula is primarily incomplete, reaching to the 
skin of the neck, which, however, it usually perforates later in life. 
This is in accord with the clinical findings in this connection. The 
opening lies in the median line of the neck at various levels between 
the hyoid bone and the jugulum. The canal itself is readily pal- 
pated — a hard cord reaching to the hyoid bone. The treatment con- 
sists in extirpation of the fistulous tract. This may be accomplished 
under local anesthesia. If portions of the duct are left behind the 
fistula reappears. 

Sistrunk^ presents the technic in detail. His presentation is excel- 
lently illustrated. 

In lateral fistula of the neck (fistula of the thymopharyngeal duct) 
the opening lies between the median edge of the sternomastoid muscle 
and the median line, between the hyoid bone and the jugulum, either 
close to the sternoclavicular articulation over the tlu'roid cartilage or 
near the body of the hyoid bone. The fistulous tract perforates the 
subcutaneous tissues, the platysma, and the superficial fascia, and runs 
upon the surface of the deep fascia parallel to the sternomastoid 
muscle, crosses the sternohyoid and thyroid, passes between the internal 
and external carotid arteries, dips under the digastric and ends in 
the lateral wall of the pharynx (Hildebrand^). It is closely asso- 
ciated with the sheaths of the deep muscles. The fistula may be 
complete or incomplete, the patent opening being either within the 

1701 



1702 SURGERY OF THE NECK • 

phar^mx or external on the neck, as stated above. The incomplete 
form may become complete as the outcome of subsequent rupture. 
The structure of the tract varies and may resemble a tubular gland. 
Although several fistulae may be present, the existence of a single tract 
is the rule. The external opening is small and discharges a mucous 
or mucopurulent fluid. Temporary closure of the opening is followed 
by swelling and pain, the latter being increased during deglutition. 
In internal incomplete fistula, food collects in the tract and gives rise 
to similar disturbances. 

The diagnosis raaj be made certain by the injection of colored fluid 
and the use of the probe. The latter does not enter the pharjnix, but 
is arrested at the lar;vTix or hyoid bone where the tract bends sharply 
inward. 

The treatment consists in complete extirpation of the tract. The 
intimate relationship that the canal bears to important structures in 
the neck makes this a difficult problem (Alivisatos^). 

The origin of lateral fistidce of the neck has been made the subject 
of considerable investigation. According to Weglowski*, the fistulous 
tract emanates from persisting rests of the thjjmopharyugeal duct, 
which is analogous to the thyroglossal. 

Congenital cysts of the neck (serous, mucous, and dermoid cysts) 
appear in various parts of the anterior portion of the neck. Like 
tistulae, the}^ may be divided into median and lateral. The lateral 
cysts usually lie between the larynx and the sternomastoid muscle, but 
they appear also between the mastoid process and the hyoid bone, and 
are found occasionallj' in the lower triangle of the neck. In either 
event, they may extend over the greater part of the neck. The 
median cysts are usuall}^ located above or below the hyoid bone, but are 
also found between the thyroid cartilage and the jugulum. They are 
rarely larger than a hen's egg and are not unlike the latter in form. 
While the superimposed skin is normal in appearance and is freely 
movable over the tumor, the cyst itself is adherent to the deeper struc- 
tures. In a sense the cysts are not congenital and do not, as a rule, 
make their appearance until about puberty. According to the most 
recent views, median cysts take their origin from the thyroglossal duct, 
and the lateral cysts from the thymopharyngeal duct and correspond 
in structure to that of the walls of the fistulas described above 
(Weglowski^). The contents of the cyst is the product of the lining 
epithelium and is usuall}^ either serous or mucous in character; but 
it may consist of a thick, fatty paste, often mixed with hair. As these 



MALFORMATIONS OF THE NECK 1703 

different constituents exist in varying proportion, a classification of 
the character of the cyst, based on its contents, is not justified. The 
terms hydrocele colli, deep atheroma, and dermoid cyst therefore are 
misapplied. 

The topographical location of congenital cysts of the neck corre- 
sponds to that of the fistulae (see above). Lateral cysts are intimately 
associated with the sheaths of the deep vessels and are often attached 
to the styloid process and the cornua of the hyoid bone. The median 
cysts are located above or below the hyoid bone. All cysts of this 
class grow slowly and do not cause disturbances unless infection super- 
venes. Their extirpation is beset with considerable difficulty; how- 
ever, no other treatment accomplishes the purpose (see Chevassu,^ 
Cignozzi,*' Morton,^ Walther^). 

Branchiogenic Outgrowths of the Skin of the Neck. — Small out- 
growths occasionally appear upon the skin of the anterior portion of 
the neck ; these may consist entirely of skin, or they may contain a 
certain amount of cartilage. They are located on one, or both, sides, 
at about midway between the sternum and the hyoid bone ; they vary 
greatly in size (wart, nipple, mushroom), and are likcl}^ to be pendu- 
lous. The growths take their origin from the second branchial arch 
and are continuous with the fascia investing the stemomastoid muscle. 
Most observers regard the anomalies as supernumerary ears, a view 
which accords with their origin. Their extirpation is readily accom- 
plished. 

Cervical Ribs. — In 1907 Keen" collected forty-three cases of cervical 
rib. The condition is really that of a supernumerary^ rib, usually 
connected with the seventh cervical vertebra. The degree of develop- 
ment varies ; the rib may extend onl}^ as far as the transverse process, 
in some instances it merges with the first thoracic rib ; in others it 
reaches as far forward as the costal cartilage and may be attached to 
the sternum. A cervical rib may be present on both sides, and occa- 
sionally two are found on the same side. 

The surgical importance of the cervical rib lies in the relationship 
it bears to the subclavian artery and the brachial plexus. The artery 
ALWAYS LIES ABOVE THE CERVICAL RIB Or, whcu the latter is too short, 
in front, never beneath it. In the same way the plexus, which lies 
beneath the rib, is also subjected to pressure. The scalenus anticus is 
often attached to the anterior end of the rib, and an intercostal muscle 
is present between the latter and the first thoracic rib. 

The cervical rib of itself does not give rise to symptoms. The 



1704 SURGERY OF THE NECK 

disturbances are due to changes in the circulation and nerve supply. 
The severity of the symptom.s, due to pressure on the subclavian artery, 
varies g-reatly. In some instances only lessening of the radial pulse 
is caused, in others, a thrombus extends from the subclavian artery to 
the periphery. Occasionally, an aneurism of the vessel develops. 
Clini-cally, the anomaly is attended with reduction in the temperature 
and pulse of the arm and hand. Gangrene has occurred. 

The symptoms arising in connection with the brachial plexus are 
those of disturbances of sensatirm, radiating neuralgic pain, pares- 
thesia, tingling, numbness, and, after a time, the limb feels heavy and 
weak. While distinct motor paralyses do not occur, the electrical 
excitability of the nerves is reduced. In a few instances atrophy of 
the muscles of the hand has occurred. Local trauma, such as a sudden 
exertion, may precipitate symptoms which attract attention to the 
condition. Reflex disturbances are analyzed by Hunt.^'^ 

The diagnosis is based on the effacement of the normal supraclav- 
icular depression, which presents a marked protrusion and exhibits a 
distinct pulsation. Palpation reveals that the protrusion is due to a 
hard bony mass and that the pulsation corresponds to the subclavian 
artery. "When the rib is very short, neither of these signs is present. 
The Rontgenogram makes the diagnosis certain. 

The treatynent consists in excision of the supernumerary rib. This 
is accompli.shed through the incision employed for ligature of the sub- 
clavian artery (p. 1023). The pleura often extends to the level of the 
rib; its injury is not attended with serious consequences (Taylor/^ 
Murphy^^), 

Wry Neck is taken up in Part VIII, chap. iv. 

BIBLIOGRAPHY 

1. SiSTRUNK. Anns. Sur?. Ixxi, 1920. 

2. HiLDEBRAND. Langenbeck's Arch. xlix. 

3. Alivisatos. Chir. Congr., 1911. 

4. Weglowski. Zentrbl. f. Chir., 1908, No. 14. 

5. Chevassu. Rev. de Chir., 1908, i. 

6. CiGNOZZi. Policlinica, xviii, 1911. 

7. MoRTOif. Bristol Med. Chir. Jr., 1911. 

8. Walther. Bull, et mem. de la soo. Chir. xxxii. 

9. Keek. Am. Jr. of Med. Sci., 1907. 

10. Hunt. Brit. Med. Jr., 1909. 

11. Taylor. Brit. Med. Jr., 1908. 

12. Murphy, Surg. Gyn. Obst. iii, 



CHAPTER II 

INJURIES OF THE NECK 

Burns. — Of the injuries of the neck, burns are of importance 
because of the gi'cat distortions sequential to healing. These should 
be obviated as far as is possible by suitable posture of the head during 
repair. 

Fractures of the Hyoid Bone. — Because of the mobility and deep 
location of the hyoid bone, it is not often fractured. Direct fractures 
occur in connection with hanging, the indirect by strangulation. The 
fragments are usuall}^ widely separated. The symptoms consist in 
painful deglutition, difficulty in speaking and cough. The fracture is 
easily palpated. Reposition is accomplished by manipulation. Fixa- 
tion is maintained by means of a gypsum or celluloid collar (Xoble^). 

Injuries of the Arteries of the Neck. — Bleeding is an important 
factor in connection with stab or incised wounds of the neck, especially 
when the latter are self inflicted. It may be divided into external, 
internal, and interstitial. In large wounds the blood is usually dis- 
charged externally; when a hollow space, such as the trachea or 
pleura, is opened, a portion of the blood is emptied into it. Extensive 
infiltration of blood into the tissues occurs when the external wound is 
small (deep stab wounds involving large vessels). The character of 
the wound and its location and extent determine the degree of bleed- 
ing, which is primary or secondary. Primary bleeding is greatest 
when a vessel is divided transversly and is always a serious problem 
in these cases. Scc&ndary hieeding occurs after five days (between 
the fifth and tenth day). It is the result of dislodgment of a throm- 
bus or of infectious destruction of the walls of a vessel or vessels. 

It is important to recognize the source of the bleeding. This, in 
many instances, is difficult, especiall}^ if the patient is m shock, when 
the character of the hemorrhage is very misleading. In most cases it 
is best to enlarge the wound and carefully explore its surfaces. The 
outcome of injuries of this sort is largely dependent upon the prompt- 
ness with which relief is afforded. The wound is temporarily tam- 
poned, its surroundings cleansed^ and the surgeon freely exposes the 

1705 



1706 SURGERY OF THE NECK 

injury and proceeds systematically to clamp and deligate all the bleed- 
ing points. When the injured area is heavily infiltrated with blood 
it is best to deligate the afferent artery in its continuity and then 
explore the site of the injury as stated. In injuries of the common 
carotid and subclavian arteries, repair of the walls of the vessel by 
suture (see Arteriorrhaphy, Part V, chap, v) may be undertaken, 
if this is warranted by the general condition of the patient. 

Injuries of the Veins of the Neck. — Although asepsis has greatly les- 
sened the occurrence of infection, injuries of veins in the neck still 
present a certain menace in this connection. To this may be added 
the dangers of fatal bleeding and the aspiration of air. As the veins 
in this situation do not possess valves and are in direct communication 
with the cranial sinuses, fatal cerebral anemia may occur when the 
latter are suddenly emptied of blood. 

Aspiration of air is most likely to be associated with injuries of 
veins situated at the root of the neck and those intimately associated 
with the fasciae and muscles, which prevent their collapse when divided. 
The entrance of air into the vein is attended with a bubbling or gurg- 
ling sound and in a few minutes the symptoms of interference with 
the circulation appear. These are by no means always followed b.y 
a fatal outcome (see Air Embolism, p. 586). 

Immediate double ligature of a divided vein should be practiced. 
Tamponade of the wound is unreliable and is justifiable only when the 
injury m the vein is inaccessible. In lateral or incomplete transverse 
section of large veins (internal jugular, subclavian, innominate) re- 
pair by suture may be made. The measure succeeds in a large number 
of cases, provided the wound is not infected (TiegeP). 

Injuries to the Thoracic Duct. — The aeep situation of the thoracic 
duct in. the neck protects it from trauma, so that its isolated injury, 
except during the emplojTnent of operative measures executed in the 
subclavian triangle, is rare. In this connection it must be remem- 
bered that the entrance of the duct into the angle formed by the 
internal jugular and subclavian veins is subject to variations, and also 
that the duct may be double. 

The danger of the injury lies in the permanent discharge of chyle 
upon the surface of the body which deprives the patient of important 
elements concerned in metabolism. However, in most instances, tam- 
ponade of the wound and repair of the duct by suture, when possible, 
is followed b}^ reestablishment of the flow of chyle into its normal 
channel (Schwinn,^ Fredet,* Parsons and Sargent'''). 



INJURIES OF THE NECK 1707 

Injuries of the Nerves of the Neck. — Division of the va^s, when 
liniitetl to oiu* side, is followed by temporary increa.se in the pulse rate, 
which is not dangerous to life. The subsequent development of pneu- 
monitis is not ascribable to section of the nerve (Jordan-Volcker*). 
Paralijsis of the recurrent laryngeal nerve is a constant result of divi- 
sion of the vagus, and impairment of deglutition is a frequent outcome 
of section of the motor fibers. 

Manipulation and trauntatic irritation of the nerve is far more 
serious in its consequences than is division. In a case operated upon 
by the writer the accidental inclusion of the vagus in the grasp of an 
artery forceps was promptly followed by death. In extensive opera- 
tions involving manipulations of the nerve its infiltration with a 1 per 
cent novocain solution is permissible. 

Injuries of the ceii'ical sijDtpathetic occur in connection with extir- 
pation of large tumors in this situation. Irritation of the ner^'e is 
attended with dilatation of the pupil, widening of the slit of the eye- 
lids, protrusion of the bulb, and coldness of the side of the face. Section 
is followed by myosis, ptosis (from paralysis of the smooth fibers of 
the muscles of the eyelids), redness and heat of the side of the face. 

Injuries of the brachial plexus are most often produced by pro 
jectiles or splintered fractures of the clavicle, either of which, is usually 
accompanied by simultaneous injury to important contiguous vessels. 
The symptoms, consisting of sensor^" and motor paralyses, vary with 
the extent of the nerve fibers involved. The question of primary or 
secondary repair of the plexus is decided by the condition of the 
wound. 

In injury of the spinal accessory nerve, involvement of its external 
branch is of surgical importance. This frequently occurs in connection 
with operations in this region. The lesion is followed by incomplete 
paralysis of the sternomasto^'d and trapezius muscles, both of which are 
also supplied by branches of the second and fourth cervical nerves. 

Aneurisms of the Neck. — As in other portions of the body, aneurisms 
of the neck are divided into true and false. Of the problems pre- 
sented in the general part of this book (Part V, chap, v) only 
those possessed of especial local intere.st will be taken up here. 

Aneurism of the common carotid artery is attended with special 
pressure symptoms, dyspnea, difficulty in swallowing, neuralgia, and 
paralysis of the hypoglossal, recurrent larjiigeal and s^nnpathetic 
nerves. Headache, vertigo, insomnia, and temporary hemiplegia are 
attributed to cerebral anemia. 



1708 SURGERY OF THE NECK 

In making the diagnosis, lymphoma of the interearotid gland must 
be excluded. 

Of the various methods of treatment, double ligature of the sac or 
aneurismorrhapJiij give the best results (Delore"). 

Aneurism of the external carotid artery is usually treated by liga- 
ture of the common carotid, although double ligature of the sac and 
its extirpation is also practiced M'ith considerable success. 

Aneurism of the internal carotid artery (extracranial portion) is 
most often the result of necrosis and perforation of the walls of the 
vessel, the outcome of deep seated inflammatory processes on the neck. 
Pressure symptoms (dysphagia) and severe headache occur very early 
in the course of the development of the lesion. 

Central ligature of the artery itself is the treatment of choice. If 
this is not feasible, ligature of the common carotid is performed. 
Aneurismorrhaphy has been practiced by IMcMullen and Stanton^. 

Aneurism of the innominate artery is not always easily diagnosti- 
cated. A conclusion in this connection should not be hastily arrived 
at. Of the operative methods of relief, peripheral ligature — i. e., of 
the common carotid and subclavian arteries — is the method of choice. 
With the view of obviating the lodgment of a liberated embolus in the 
brain, the carotid should be tied first (Guinard^). 

In aneurism of the third portion of the subclavian double ligature 
and extirpation of the sac may be practiced. Aneurismorrhaph}' has 
been executed with success (Savariaud"). 

Arteriovenous aneurism of the common carotid and internal jugular 
is of especial interest on the ground that, in a number of instances, 
immediate exposure of the injury and repair by suture of the opening 
in the vein and artery is frequentlj^ followed by restitution to the 
normal (Herzen^^, See also Sencert^^). 

BIBLIOGRAPHY 

1. Noble. Anns. Surg:., Aug., 1896. 

2. TiEGEL. Zentrbl. f. Chir., 1911. 

3. ScHwiNN-. Anns. Surs:., 1896. 

4. Fredet. Presse med., 1910, No. 1. 

5. Parsons and Sargent. Lancet, 1909. 

6. Jordan und Volcker. Handb. d. prakt. Chir. ii, Stuttgart, 1913. 

7. Delore. Rev. de Chir., 1907, i. 

8. ]\IcMuLLEN and Staxton. Anns. Surg., 1910. 

9. GuiNARD. Rev. de Chir., 1909, ii. 

10. Savariaud. Rev. de Chir. xxvi. 

11. Herzen. Congr. Chir., 1910. 

12. Sencert. Med. and Surg. Therapy, iii, N. Y. and London, 1918, 



CHAPTER III 

DISEASES OF THE NECK 

Acute Phlegmons and Abscesses. — Acute phlegmons and abscesses of 
the cellular tissues of the neck are caused by (a) direct infections 
of wounds of the skin and mucosa; (b) extension of infection from 
neighboring inflammatory processes; (c) conveyance by way of the 
lymph channels; (d) hematogenous invasion. 

The peculiarities of these processes are due to the anatomical con- 
ditions presented in the neck. 

Su'bmaxnJa7'}j 'phlegmons and abscesses are by far the most frequent ; 
they are usually lymphogenous in origin and arise in connection with 
carious teeth, periostitis of the mastoid process, or ulceration of the 
gums ; or from lesions of the face. As a rule, the inflammation takes 
on the form of a periadenitis and extends from the anterior edge of 
the sternomastoid muscle to the chin. This region is markedly swollen 
and infiltrated and presents the typical picture of inflammation. At 
times, the hardness of the infiltrate justifies the use of the term wooden 
phlegmon (p. 325). In a certain number of cases, the invasion of the 
deep cellular tissues of the neck is very extensive, presenting a con- 
dition of affairs (often fatal) to which the term Ludivig's angiria 
(p. 325) has been applied. The process is at this time regarded as a 
particularly virulent fojm of infection of the tissues mentioned. The 
contiguous cellular tissue of the floor of the mouth, larjTix, and 
pharjTix are infiltrated by inflammatory edema (Price,' Turner,^ 
Thomas^). 

The symptoms are fairly uniform. Aside from those due to sys- 
temic disturbances, dysphagia and swelling appear promptly. The 
head is held inclined toward the affected side, and the swelling of the 
floor of the mouth causes the tongue to protrude from the mouth, 
which can only be slightly opened. Mastication is impossible; the 
saliva dribbles, and the breath emits an offensive odor. Death occurs 
from exhaustion or may be the outcome of edema of the glottis. In 
less severe cases, the process goes on to the formation of an abscess 
which ruptures intj> the mouth or upon the surface of the neck. 

1709 



1710 SUKGERY OF THE NECK 

The treatment consists in free incision of the infiltrated tissues; 
fluctuation should not be awaited. The sooner the pressure on the 
tissues is relieved the better. Tracheotomy may be necessary. 

Submental phlegmons usually arise in connection with infection of 
the submental lymph nodes derived from rhagades, ulcers of the 
frenulum, furuncles of the chin, etc. They show little tendency to 
extend. The incision should be vertical. 

Phlegmons and abscesses of the connective tissue of the vessel sheaths 
occur as a part of angina. The ports of entrance of the infection are 
carious teeth, the scalp, otitis, ozena, and stomatitis. The affection 
often develops during scarlatina. The clinical picture is very similar 
to that described in connection with submaxillary phlegmon, except 
that the swelling and infiltration appear at first along the sterno- 
mastoid muscle, from which it extends in all directions, especially 
downward to the supraclavicular region. In some instances, the 
process gains access to the anterior mediastinum, the pha^}^lx, the 
esophagus or the trachea. Early incision is indicated. Search for 
exudate in the deeper tissues is made with a closed forcipressure. 

Abscesses of the supraclavicular region originate in the deep cervical 
glands or gravitate from the upper areas of the neck. The exudate 
usually perforates the platysma, but in some instances it proceeds 
along the sheath of the vessels and gains access to the axilla. 

Diffuse phlegmon of the neck often presents itself in a particularly 
virulent form, especially in children (during acute infectious diseases), 
and in adults afflicted with phthisis, diabetes, malignant tumors, alco- 
holism, etc. Phlegmon of the carotid sheath {ahsces profond de Chas- 
signac; phlegmon large du cou de Dupuytren) is particularly 
menacing. Many of these cases die from the severity of the infection, 
while a certain number progress to abscess formation. This form of 
phlegmon is very likely to perforate into one of the large vessels of 
the neck (Jordan-Yolcker*). 

Acute lymphangitis of the neck usuall}^ attends one of the processes 
just discussed. 

Chronic Inflammatory Processes of the Neck. — In the development 
of chronic inflammatory processes of the neck, tuberculosis, actinomy- 
cosis and syphilis play the leading roles. Of these, tuberculosis is the 
chief aggressor. 

Chronic lymphadenitis (simple hyperplastic lymphoma) is a term 
applied to enlargement of the lymph nodes caused by the prolonged 
absorption of irritating substances of a chemical or bacterial nature ; 



DISEASES OF THE NECK 1711 

the nodes do not show a tendency to su])purate (see Diseases of the 
Lymphatics, Tart V, chap. iv). The provocative factor consists in 
one of a variety of conditions, such as eczema, catarrh of the mucous 
memhranes of the nose and pliarynx, chronic bh'pharitis, hypertrophy 
of the tonsils, ulceration of the gums and caries of the teeth (Stark''). 
The affection is especially prevalent in cliildren. 

The differential (lia(j)iosis takes into account tuberculosis and malig- 
nant disease ; only the former may be recognized by the microscope. 
The treatment consists in removal of the cause. 

Tuberculosis of the lynrph nodes of the neck (tuberculous lymph- 
oma) is very common. An elaborate regional classification is olFered 
by Jordan and Volcker.* The process appears in the several forms. 

1. In the purely hyperplastic form, the bacillus does not provoke 
nodular thickening of the glands. This is simply a very mild form 
of the infection. 

2. In hjiperplasio), with the formation of nodules, the nodes are 
visible to the eye and vary in size from that of a hazel nut to a hen's 
egg, depending upon the severity of - the infection. 

3. Caseation occurs w^hen the tuberculous tissue breaks down ; this 
may ck^velop in only a part of the infected nodes. Liquefaction is an 
advanced stage of caseation. 

4. Fistula formation is the outcome of invasion of the perinodal 
tissues by extension through the capsule of the gland. The latter 
undergoes a hj'perplastic thickening, in which it becomes adherent to 
the contiguous nodes and to the surrounding tissues. Finally, this 
connective tissue growth also breaks down and the process invades the 
skin, where small abscesses are formed which empty their contents on 
the surface of the body. This presents conditions exceedingly favor- 
able to the entrance of pyogenic excitants, in which event a so-called 
mixed infection develops. On the other hand, the expulsion of disin- 
tegrated tissue is not rarely followed by spontaneous healing of the 
process. 

The etiology of tuberculous lymphadenitis of the neck is chiefly 
concerned in the manner in which the infection invades the lymph 
channels. Primary lymphatic tuberculosis probably does not exist 
and its hematogenous origin is regarded as unlikely. The theory that 
the process extends upward from the lung is equally improbable. 
There is no doubt that the chief ports of entrance in tuberculous 
lymphoma of the neck are located in the upper portions of the head 
and neck; i. e., the process is to be regarded as secondary and is due 



1712 SURGERY OF THE NECK 

to the migration of the bacilli by way of the lymph channels. It 
seems to have been shown that the excitants may penetrate through 
intact skin and mucosa ; there is no doubt that they may enter through 
a patch of eczema (FraenkeP). The usual ports of entrance are 
carious teeth (Stark^'), the mucosa of the gums (Mathews^), and the 
tonsils, including the phar>Tigeal tonsil (Judd,* Eisendraht," Os- 
borne^"). The affliction is rare in well nourished individuals and is 
most common in children. 

The clinical picture is that of a slowly developing enlargement of 
the Ij'mph nodes of the neck attended with moderate or no constitu- 
tional disturbances. The nodes are, at first, movable and may remain 
so. When periadenitis occurs they adhere to the surrounding tissues. 
In some instances the glandular enlargement is very great, the process 
presenting a large nodular tumor. Before rupture, tuberculous 
abscesses appear in the form of a low grade of inflammation involving 
the superficial tissues. 

The diagnosis, in cases in which abscess and fistulae are formed, is 
not difficult ; however, this stage bears considerable resemblance to 
actinomycosis, and perhaps to gumma. In elderly persons, Ij^mpho- 
sarcoma must be excluded with the aid of the microscope. Difficulties 
arise when there is no periadenitis. In children, confusion with simple 
chronic hyperplasia is common. In doubtful cases the microscope 
must decide the question. In the second and third deceniiium, pseudo- 
leukemia must be excluded; clinical differentiation is impossible. 
Malignant disease of the lymph nodes must also be taken into account. 

In the treatment, prevention of invasion of the Ijonph channels must 
be considered. Lesions of the upper neck, the throat and the head 
must receive proper care. The constitutional treatment of tubercu- 
losis is exceedingly important. The use of the Rontgen ray seems to 
possess considerable value (Pirie," Kienbock,^^ Holding." See also 
Part II, chap, xxiii). 

The operative treatment is indicated when the capsules of the glands 
are involved. It should be carried out before periadenitis is advanced. 
When the nodes are movable, the technic is not difficult ; later in the 
process the anatomical landmarks are likely to be effaced. The incision 
should be placed so that subsequent scarring is reduced to a minimum. 
For invasion of the upper triangle of the neck, the incision extends 
from the tip of the mastoid process to the middle of the hyoid bone, 
passing one finger's breadth below the angle of the jaw. The digas- 
tric, stylohyoid, geniohyoid, mylohyoid and hyoglossus muscles lie 



DISEASES OF THE NECK 



1713 



above; the sternohyoid, thyrohyoid and omohyoid below, and the 
sternomastoid behind the line of exposure, which also permits of avoid- 
ance of the vagus, sympatheticus, accessorius, the lower branch of the 
facial, the hypoglossal, lingual and glossopharyngeal nerves. The 
lower triangle is readily invaded through an incision midway between 
the one just described and the clavicle and parallel to the former. 
Enucleation of non-adherent glands through an incision located at the 
back of the neck (DoUinger^^) is a dangerous measure. When peri- 
adenitis is present, the 
line of incision is decided 
by the extent of the 
process. In these cases, 
the curet must often be 
resorted to. In extensive 
involvement, extirpation 
of the process is accom- 
plished through wide, 
atypical incisions, which 
include the formation of 
flaps and also provide for 
division of the sternomas- 
toid muscle in order to 
Fig. 819.— Incision for Kemoval of Tubercu- gain access to the infected 
LOUS Lymph Nodes OF Neck. nodes (Fig. 819) (de 

a, Point of division of sternomastoid muscle; nnpvvpi'n « PlnrnTTiPr " 
b, c, d, line of incision (Hartley). l<^uervam, riummer, 

Parker,^^ Courtney^^). 
The end results of operative treatment seem to justify its employ- 
ment. In this connection the statistical review of Dowd^® is particu- 
larly illuminating. Of 245 cases operated upon by himself, only 45 
required secondary operation. 

Lues of the Neck. — Primary luetic adenitis occurs in the neck in 
connection with chancre of the lip, the tongue and the tonsil. The 
process is attended with pain and swelling and must be differentiated 
from acute suppurative adenitis. 

In the secondary stage of lues the cervical glands are almost always 
involved and often remain more or less enlarged for years. The nodes 
do not reach a great size, are painless, and are freely movable; i. e., 
periadenitis does not develop, an important differential diagnostic point 
as regards tuberculosis. 

Tertiary luetic adenitis in the neck appears in the form of a gunj'' 




1714 SURGERY OF THE NECK 

matous lymphoma. The lesion is rare and presents itself at first in the 
form of hyperplasia of a single nodule, or group of nodes, which soon 
coalesces with the surrounding tissues (periadenitis luetica), becomes 
adherent to the skin and ultimately breaks down ; this is followed 
by the formation of a typical luetic ulcer. In the diagyiosis, the thera- 
peutic test should not be omitted ; however, as stated in connection 
with carcinoma in general (p. 1283), this must not be extended over a 
period of more than two weeks. 

The sternomastoid muscle is at times the seat of a peculiar luetic 
infiltration (luetic myositis) which may be diffuse or circumscribed 
(HonselP"). Elliot-^ has collected a number of cases of lues of the 
hyoid hone. 

Actinomycosis of the Neck. — Excluding the jaw and the cheek, the 
neck is most often invaded by the ray fungus. As a rule, the infec- 
tion in this situation is a part of that developing in the mouth, where 
the excitants gain access to the tissues through carious teeth, ulcers in 
the mucosa, and through the seemingly ever receptive tonsil. The 
lesion usually makes its appearance in the region of the lower jaw and 
extends downward by direct extension —- not by the lymphatics. The 
proeess presents the clinical picture of a slowly progressing low grade 
of destructive inflammation which soon develops numerous fistulous 
tracts. The exudate contains the ray fungus. A peculiarity of the 
disease is that it heals in one area, while extending to another. The 
diagnosis is certain only when the microscope reveals the causative 
fungi. 

The treatment consists in curettement of the lesion and the admin- 
istration of iodin. The latter does not have any direct effect upon the 
ray fungus, but seems to place the tissues in a condition to resist its 
propagation. Rosenfeld-- reports favorable results following the 
injection of Lugol's solution (3 per cent), which he combines with the 
administration of potassium iodid in increasing doses (see also Shiota-^ 
and Part II, chap, xix, of this work). 

BIBLIOGRAPHY 

1. Price. Anns, of Surg., 1908. 

2. Turner. Anns, of Surg., 1908. 

3. Thomas. Anns, of Surg., 1908. 

4. JoRDAN-VOLCKER. Handb. d. prakt. Chir., Stuttgart, 1913, ii. 

5. Stark, v. Bruns' Beitr. z. klin. Chir. xvi. 

6. Fraenkel. Prager Zeitschr. f. Heilkunde, 1885. 

7. Mathews. Anns, of Surg., 1910. 



DISEASES OP THE NECK 1715 



8. JuDD. Anns, of Surg., 1910. 

9. EiSENDHAiiT. Amer. Jr. of Surg., 1907. 

10. OscouNK. Brit. Med. Jr., 15)11. 

11. PiKiE. Med. Press, 1909. 

12. KiENBOCK. Riiiitgen. Tasfhonbueh, iii. 

13. Holding. All)anv Med. Anns., 1910, xxxi. 

14. DOLLiNGER. Zenh-bl. f. Chir., 1908. 

15. DE QuERVAiN. Scuiaine ]\Ied., Paris, 1900. 

16. Plummer. Surg. Gyn. Obst., 1907. 

17. Parker. Brit. Med. Jr., 1908. 

18. Courtney. Lancet, 1907. 

19. DowD. Anns, of Surg., 1908. 

20. HoNSELL. V. Bruns' Beitr., etc., xxii. 

21. Elliot. Quoted by No. 4. 

22. RosENFELD. Prag. med. Woch., 1896. 

23. Shiota. Deutschi. Zeitschr. f. Chir. cL 



CHAPTER IV 

TUMOES OF THE NECK 

Cystic Tumors. — Congenital cystic hygromata (cystic lymphangio- 
mata) occur early in life. They usually begin in the subcutaneous 
fatty tissue and extend into the deeper connective tissue, though at 
times a hygroma takes its origin from the sheaths of the large vessels. 
As the growth enlarges it extends betM^een the various parts of the 
neck (esophagus, trachea, etc.) and gains access to the mediastinum, 
the pharynx and the mouth. It does not usually possess a connective 
tissue capsule, a circumstance which much enhances the difficulty of its 
removal. The benign character of the process is evinced by the fact 
that it does not destroy the tissues contiguous to it. 

Clinically , a hygroma presents itself in the form of a laxly fluctuat- 
ing tumot with a smooth surface. It is translucent through the 
atrophic superimposed skin. The latter is occasionally thickened 
(elephantiasis) and the superficial veins are dilated. Pressure does 
not reduce the size of the tumor. The growth is composed of dilated 
lymph vessels (Wegner^) and its contents consist of a clear serous or 
milky fluid which, when mixed with blood, may be brown in color ; it 
readily coagulates. The interior of the cyst presents a number of 
cavities of varying sizes. The tumor grows very slowly, but often 
assumes enormous dimensions. In the diagnosis, branchiogenic cysts 
must be taken into account; these are recognized by their typical 
location. In doubtful cases aspiration clears up the situation. The 
treatment consists in extirpation of the cyst — not an easy problem 
(Patzold^). 

Blood cysts in the neck owe their origin to fetal arrest of develop- 
ment ; a preexisting branchiogenic cyst ; dilatation of a vein ; a cav- 
ernous angioma, or a lymphangioma. Their recognition is based on 
the facts that the cyst enlarges during coughing or other exertion and 
that it may be emptied by pressure and does not pulsate. Extirpation 
of the cyst is the treatment of choice ; however, obliteration of the sac 
has been accomplished by prolonged pressure with bandages and by 
the injection of iodin ; the latter is not without danger. 

1716 



TUMORS OF THE NECK 



1717 



Athcromata of the skin of the neck are not common (see Part VII, 
chap. i). 

Bursal cysts of the hyothyroid region develop in connection with 
mechanical irritation and rheumatism. Enlargement of the bursae 
over the thyroid isthmus may bo mistaken for a cyst of the latter. 
On the other hand, a positive diagnosis of a cystic bursa in the thyro- 
hyoid region is not feasible until the lesion is exposed. 

Echinococcus cysts of the neck are exceedingly rare. The diagnosis 
is made only during extirpation of the growth (Bevers^). 

Blood Vessel Tumors of the Neck. — Angioma simplex appears in the 

neck in the form of a 
flat nevus and sub- 
cutaneous angiomata. 
The latter develop 
most often in the 
region of embryonic 
clefts (fissural angio- 
mata). They may be 
destroyed b y igni- 
puncture or excised. 
Angiomata caver- 
nosa appear in the 
superficial and deep 
forms. As a rule, 
they develop in adult 
life and are often the 
outcome of the simple 
form of angioma. 
Like all tumors of 
this sort, they may be 
emptied by pressure 
and return when this 
is released. While 
ignipuncture and the 
injection of alcohol has been followed by obliteration of the vessels, 
extirpation of the process is desirable. This is, however, attended 
with some difficulties (Eisenreiter*). 

Solid Tumors of the Neck. — Fibromata of the neck are divided into 
the superficial and deep. Superficial fihromata arise from the cellular 
tissues of the skin and from the subcutaneous tissues (see v. Reckling- 




FiG. 820. — Hygroma of the Xeck. 



1718 



SURGERY OF THE NECK 



hausen's Disease, Part V, chap. i). Deep fibromata originate from 
the aponeuroses and the periosteum of the vertebrae (Jordan^), and 
may reach the size of a child's head. 

Fibromata grow slowly and cause disturbances by making pressure 
on important parts (d^'spuea and interference with deglutition). The 
diagnosis is not difficult ; it is based on their firm consistence and slow 
growth. The latter characteristic differentiates them from sarcoma. 
The}' should be extirpaied, a measure which is difficult only when the 
tumor is large and its origin deeply located. 




Fig. 821. — Fibrolipoma of Neck. 



Lipomata seem to show a predilection for the neck. The circum- 
scribed form presents a characteristic sharp outline (see Part VI, 
chap, vii) ; however, occasionally a lipoma of this sort attains a very 
large size. Subfascial lipomata cause disturbances by pressure upon 
the trachea and esophagus. Those located in the supraclavicular 
region are likely to cause neuralgia (pressure on the brachial plexus) 
or obstruct the subclavian vein ; the latter gives rise to edema of the 
arm. The diffuse form, of lipoma (Madelung's® fat neck) is discussed 
in the general part of this book. 

The clinical picture of lipoma is so characteristic that the diag- 



TUMORS OP THE NECK 1719 

nosis sliould be readily made. On the other hand, subfaj>cial lipoma 
(•annul, be diagnosticated until it is exposed. Extirpation is not diffi- 
cult, except in so-called fat neck, in which instance it is necessary to 
achieve the purjjose in several sittings (Debrez"), 

Neuromata of the superficial tissues of the neck do not present any 
regional peculiarities. Of the deeply located neuromata, those orig- 
inatnig from the vagus are of importance. Jordan and Volcker* 
([uote four cases collected by Semel and add one of their own seen in 
Lexer's clinic. Attention is called to the tumor by persistent hoarse- 
ness and the attendant cardiac disturbances. Removal of the tumor is 
followed by paralysis of the recurrent laryngeal nerve. 

EncJiondromata of the neck do not present regional peculiarities 
beyond the pressure symptoms. 

Malignant Tumors of the Neck. — Malignant tumors of the lymph 
nodes of the neck include the general class of sarcomata. However, 
the process possesses so many histological differences that a classifica- 
iion in this connection is impossible. A rough clinical division into 
Hodgkin's disease, which is attended with enlargement of the lymph 
nodes in various portions of the body, and lymphosarcoma of a single 
node or cluster of nodes is as far as one is justified in going at this 
time. Both of these processes are taken up in Part VI, chap. xi. 

Lymphosarcoma in the neck is not common. It appears in the form 
of a smooth, soft, movable, painless tumor covered with normal skin. 
As the growth enlarges, smaller nodules appear at its periphery, which 
soon merge with the primary tumor, until a large nodular mass is 
created. After a time, the growth becomes adherent to the skin, the 
muscles, and the deep vessels and nerves, and causes pressure upon the 
trachea and esophagus. As the process progresses, the skin breaks 
down and the protruding tumor undergoes disintegration. The entire 
course of the disease rarely extends over a year and a half. Strange 
to say, lymphosarcomata of the neck do not frequently form 
metastases. 

The treatment is very unsatisfactory. Early extirpation of the 
growth holds out the only hope of relief. The use of the X-ray should 
not be withheld, although its therapeutic value is, to say the least, 
doubtful. The employment of serum is taken up in Part VI, 
chap. xi. 

Primary carcinoma of the neck, involving the skin, is uncommon ; 
it does not possess any regional peculiarities. Branchiogenic carci- 
nomata begin in the deeper structures of the neck and are believed to 



1720 SURGERY OF THE NECK 

originate from residual epithelial cells displaced during embryonic 
development. 

An exact diagnosis is impossible. On the other hand, the malignant 
character of the process .should not escape recognition. It is important 
to differentiate it from growths that are secondary to hidden carcinoma 




Fig. 822.— Lymphosarcoma of the Neck. 

of the nose, lar^Tix, pharynx, etc. Differentiation from carcinoma of 
aberrant tlnToid glands is possible onh* with the aid of the microscope. 
As in all malignant growths, sarcoma, tuberculosis, actinomycosis and 
lues must be taken into account (Fredet, Labay, Chevassu,^ Forque et 
Massabuau,^° Duthre,^^ Duret^-). 

Teratomata are usuallj^ situated in the side and anterior portions of 



TUMORS OF THE NECK 1721 

the neck. The dia^osis is usually made after extirpation (Niosi/* 
Hardouiu/^ and also Part VI, chap, xxii, of this book). 

BIBLIOGRAPHY 

1. Wegner. v. Langenbeck's Arch. xx. 

2. Patzold. v. Bruns' Beitr. li. 

3. Bevers. Brit. Med. Jr., 1907. 

4. EiSEXKEiTER. Munch. Med. Abhandl., 1894. 
• 5. Jordan. Ziegler's Beitr. path. Anat. viii. 

6. Madelung. v. Langenbeck's Arch, xxxvii. 

7. Debrez. Arch, gen de Chir., 1910. 

8. Jordan- VoLCKER. Handb. d. prakt. Chir. ii, Stuttgart, 1913. 

9. Fredkt, Labay, Chevassu, Bull, et mem. soc. anat., 1908. 

10. Forque et Massabuau. Province med., 1908. 

11. DuTiiRE. Jr. de med. de Bordeaux, 1908. 

12. Buret. Bull, de I'aead. de med., 1907. 

13. Niosi. XX congr. soc. ital. chir., 1907. 

14. Hardouin. Bull. soc. anat., 1908. 



CHAPTER V 

SURGEEY OF THE LARYNX AND TRACHEA 

Examination of the air passages entered a new era when the now 
so familiar laryngeal mirror was introduced (1858) and the usefulness 
of the method was enormously enhanced by the introduction of cocain 
anesthesia (1884). While laryngology is largely in the hands of the 
specialist, the problems met with in this connection are often of a 
nature requiring the cooperation of the surgeon ; a desideratum per- 
haps not as fully realized as it should be. However, the picture 
presented to the examining eye by the mirror is indicative of the 
condition of only a narrow area of the lar^-nx, and is of course much 
distorted. This has led to the development of direct laryngoscopy 
which has made great strides since Kirstein^ first published his method 
in 1894. The next step in this connection was presented by Killian,^ 
who devised upper bronchoscopy, and later developed direct hroncJio- 
scopy. 

Direct inspection of the air passages is based on the introduction of 
a straight metal tube, per vias naturales, into the bronchi. The technic 
of the procedure has been developed by Brlinings,^ who devised the 
instrument shown in Figure 823. It consists of two telescoping tubes. 
The outer terminates in a taper, which facilitates its introduction into 
the larynx; the inner is introduced through the outer and is held in 
place by a spring which prevents its expulsion. Light is furnished 
b}^ an electrical bulb and condenser which are attached to the proximal 
end of the apparatus. During the examination the patient may be 
postured in the sitting (Fig. 823) or the supine position; the latter 
is preferable. The mucosa is cocainized. Albrecht* has devised a 
"swivel spatula" which makes additional exposure of the air passages 
possible. With, this instrument it is feasible directly to visualize the 
trachea and both bronchi {tracheography and hronchometry) . Low 
bronchoscopy through a tracheotomy wound, except perhaps for re- 
moval of a foreign body, is no longer necessary. 

Malformations of the Larynx. — Malformations of the larynx are 

1722 



SURGERY OF THE LARYNX AND TRACHEA 1723 



practically limited to adherence of the epiglottis to the base of tlie 
tongue, and to congenital diaphragm of the larynx. 

Congenital diaphragm of the larynx is of surgical importance. The 
glottis is more or less obstructed b}^ a membrane located between the 
vocal cords. The condition is ascribed to incomplete patency of the 
rudimentary trachea. The treatment consists in excision of the adven- 
titious membrane. In most instances this may be accomplished by the 




Fig. 82.3. — Position op the Uni\t:rsal Electroscope (Bruning's) with the 

Patient Seated. 

endolaryngeal route; however, in a certain number of cases, prelim- 
inary laryngotomy is necessary (Hansberg^). 

Laryngoceles and Tracheoceles (Areoceles). — Although gener- 
ally ascribed to traumatic causes, there is no doubt that areoceles are 
due to at least a predisposing (congenital) malformation favoring 
their development. 

The congenital form consists of a hernial protrusion of the mucosa. 
Laryngocele (single or double) is situated at the side of the thyroid 



1724 SURGERY OF THE NECK 

cartilage. The diagnosis is based on the fact that the sac is distended 
during expiratory efforts and may be emptied by pressure. Tracheal 
protrusions may be mistaken for cysts of the thyroid gland. In some 
instances the exact condition is not recognized until the protrusion is 
exposed (Petit**). 

Concussion of the Larynx (Commotio laryngis). — Severe dyspnea, 
syncope and death have occurred in connection with trauma applied 
to the larynx without the presence of demonstrable solution of con- 
tinuity. Theoretically, the employment of artificial respiration and, 
possibly, tracheotomy are indicated (Lubet-Barbon'^). 

Fracture of the Larynx and Trachea. — Fracture of the larynx is pro- 
duced by lateral compression or by flatteni^ig of its sagittal diameter 
by pressure against the vertebral column. Of the accidental causes, 
a fall, a blow, or strangulation are the most frequent (see Hopmann's^ 
collection of 145 cases). Most of the fractures are transverse; how- 
ever, the solution of continuity of the cartilage may be in any direction 
and is not infrequently comminuted and even compound. The asso- 
ciated injury of the soft parts is likely to be extensive. Effusion of 
blood occurs within the larynx and also infiltrates the surrounding 
tissues. Edema may obstruct the lumen of the larynx to a dangerous 
extent. 

The symptoms are those of a severe injury. In almost all instances, 
consciousness is temporarily lost (commotio laryngis) . Cough, usually 
attended with bloody sputum, is a very frequent occurrence ; pain is 
severe, especially when coughing or swallowing; the voice is rough, 
hoarse or absent. Primarily, respiration is much disturbed; then is 
less so ; later is still more embarrassed ; and soon develops stridor. 
The patient becomes cyanotic and is apprehensive of choking to death ; 
the pulse is small, the skin pale and moist. As the edematous and 
bloody infiltrate of the mucosa increases, the respiratory difficulties 
are amplified. When the mucous membrane is ruptured, the surround- 
ing cellular tissues, and later those of nearly or quite the entire body, 
are invaded by emphysema (Part III, chap. i). To this must be 
added the classic symptoms of fracture. Despite the menacing pic- 
ture, the prognosis is not very unfavorable. A fatal outcome is caused 
by suffocation due to edema, accumulation of blood in the lungs, 
mediastinal emphysema, and aspiration pneumonitis. Repair takes 
place by callus formation. Late disturbances are ascribable to 
reparative narrowing of the lumen of the larynx. 

The treatment aims at maintaining the free passage of air into the 



SURGERY OF THE LARYNX AND TRACHEA 1725 

lungs. As soon as dyspnea occurs, tracheotomy must be performed. 
However, the dyspnea may be caused by bleeding in the interior of the 
larynx, in which event tracheotomy is of no avail. In these cases, pre- 
liminary tracheotomy, median laryngofissure and tamponade of the 
larjmx and repair of the structures in layers is indicated (Wagner"). 
Fracture of the trachea is caused by the same influences discussed 
in connection with the larynx. The solution of continuity may be 
complete or incomplete; usually it is located just beneath the larynx 
or at the tracheal bifurcation. The clmical picture is very similar to 
that presented in connection with fracture of the larynx. The diag- 
nosis is based on the fact that this is presented while the larynx is 
intact. The prognosis is unfavorable. The treatment follows the same 
principlCvS applicable to the larynx. To this may be added, that 
d>'«pnea should not be awaited before operative efforts at repair of the 
lesion are made (Hansberg''). 

BIBLIOGRAPHY 

1. KiRSTEiN. Heymann's Handb. d. Laryng. u. Rhinol. i. 

2. KiLLiAN. Miinch. med. Woch., 1898. 

3. Brunings. Die Laryngosk., Bronchosk., etc., Wiesbaden, 1910. 

4. Albrecht. Berlin, klin. Woeh., 1912. 

5. Hansberg. Katz, etc., Handb. d. spec. Chir., etc., Wiirtzburg, 1912. 

6. Petit. Rev. de Chir., 1889, ix. 

7. Lubet-Barbon, in Dentu et Delbet, Traite de Paris, 1898. 

8. HoPMANN. Same as No. 1 (complete bibliography). 

9. Wagner. Quoted by v. Bruns-v. Hohmeister in Handb. d. prakt. Chir., 

Stuttgart, 1913. 



CHAPTER VI 
WOUNDS OF THE LAEYNX AND TRACHEA 

Gunshot Wounds. — Gunshot wounds of the larjaix are really com- 
plicated fractures of this organ, which is usually splintered, and 
are attended with more or less trauma to the vocal cords. The clinical 
picture and the treatment of the injury are similar to those discussed 
in connection with fracture. 

Incised and Stab Wounds. — Incised and stab wounds of the larynx 
are most often self inflicted or are the result of attempted murder. 
The former are usually transverse and may involve the hyothyroid 
membrane, the thj^roid cartilage, or the cricothyroid space. Wounds 
of this sort gape widely ; occasionally inspiration draws the lower flap 
into the larynx and obstructs respiration. Dyspnea may also be 
caused by the flow of blood into the trachea, submucous hematoma, 
edema and abscess formation. 

The diagnosis is difficult ovlIj in cases of stab wounds of the trachea, 
in which event the presence of bloody expectoration and the occur- 
rence of emphj'^ema decide the question. Healing is slow, even after 
repair by suture (20 to 30 days). 

In the treatment of wounds of the larynx and trachea the chief 
factors are to maintain the free passage of air to the lungs and to arrest 
bleeding. Blood that has flowed into the bronchi may be removed 
through a sterile catheter by suction. In all cases, prophylactic trach- 
eotomy is imperative. If the larynx is splintered and the soft parts 
severely traumatized, the wound should be cleansed and treated by 
the open method. On the other hand, in cases presenting less severe 
injury, an effort should be made to obtain union by primary intention. 
However, as this is not frequently crowned with success, ample pro- 
vision for drainage must be made (Platt^). While circular repair by 
suture of the completely sectioned trachea has been successfully car- 
ried out on several occasions, the external wound must be drained and 
a simultaneous tracheotomy performed. As a rule, gunshot wounds 
are best treated by the open method (Boljarski^). The sequential 
cicatricial stenoses are taken up later (p. 1737). 

1726 



WOUNDS OF THE LARYNX AND TRACHEA 1727 

Burns. — Burns and chemical cauterization oi' the hirynx and trachea 
are the result of aspiration of heated air (or the Hanie) or of the How 
of heated or caustic (acid or alkaline) fluids into the air passaj,'es. 

The clinical picture is that of edematous swelling of the tissues, espe- 
cially in the zone of the epiglottis and the arycpiglottidean folds. 
However, this may extend into the lar^'nx and trachea, particularly 
when the condition is due to a caustic fluid. The chief sytnpto))is are 
dyspnea, painful deglutition and coughing ; the last is especially dis- 
tressing. The treatment consists in tracheotom}' and the modern meth- 
ods of local anesthesia. Impregnation of the inspired air with moisture 
contributes very much to the patient's comfort (Pitts,^ Hopmann^). 

BIBLIOGRAPHY 

1. Platt. Brit. Med. Jr., 1897. 

2. BoLjARSKi. V. Bruns' Beitr. Ixxvii, No. 2. 

3. Pitts. Brit. Med. Jr., 1893. 

4. HoPMANN, in Heymann's Handli. d. Laryng., etc., i, Vienna, 1898. 



CHAPTER VII 
FOEEIGN BODIES IN" THE AIR PASSAGES 

Most foreign bodies gain access to the air passages per vias naturales, 
although occasionally one enters through their walls (projectile, 
needle, tracheotomy tube, sequestrum from one of the vertebrae) . As 
a rule, the entrance is precipitated by a sudden forced inspiration 
caused by fright, laughter or a fall. The presence of disturbances of 
motility of the larynx, the sequelae of a pathological condition (diph- 
theritic or bulbar paralj'sis, chronic inflammatory processes, etc.) favor 
the entrance of articles of diet and fluid into the air passages. The 
aspiration of foreign bodies is favored by abolition of the reflex excit- 
ability of the larynx (sleep or narcosis). The character of the foreign 
body varies greatly; the most common are false teeth, tobacco cuds, 
bonbons, and coins. V. Bruns and v. Hofmeister^ present an interest- 
ing review of the literature in this connection. 

The localization of the foreign body also varies, and in a measure 
is decided by its size. Of 646 cases collected by Heller,^ 132 were in 
the larjTix, 113 in the trachea, 161 in a bronchus, and in 240 the 
exact location is not stated. 

A practicable division may be made into movable (fluttering) and 
immovable bodies (impacted). The former are found only in the 
trachea and bronchi ; those located in the larjTix are always immovably 
fixed in the sinus of Morgagni or in the glottis. Many bodies are 
arrested at the bifurcation of the trachea. As no air gains access to 
the portion of the lung obstructed by the invader, there is no expira- 
tory vis a tergo, consequently, inspiration only serves to more tightly 
impact it (Gottstein^). 

The changes in the tissues produced by the presence of the foreign 
body vary with its location and character and with the length of time 
it remains in situ. In the larynx, the protracted presence of the of- 
fending agent is followed by strong reactive inflammation, or pressure 
necrosis develops at once. These processes are both attended with 
edema of the surrounding tissues (especially the glottis). Necrotic 

1728 



FOREIGN BODIES IN THE AIR PASSAGES 1729 

destruction of tissue often extends into the deep tissues, perforates the 
larynx, and invades the deeper structures of the neck. In some in- 
stances, the perforation extends into the esophagus; in others (very 
few), a perilaryngeal abscess is formed, which ruptures and the for- 
eign body Ls discharged. Erosion into the large blood vessels and fatal 
bleeding has occurred. In other cases the reaction is limited to prolif- 
eration of granulation tissue. A small body, such as a needle, may 
become encapsulated. 

A most severe reaction is developed in connection with the entrance 
of a foreign body into the deeper air passages. This is followed by 
trachitis and bronchitis with purulent secretion, inflammatory and 
cicatricial stenoses, recurring bronchopneumonitis, and abscess and 
gangrene of the lung. Occasionally, a foreign body perforates into 
the pleural sac and empyema develops. If a bronchial lumen is en- 
tirely occluded, the distal portion of the lung undergoes so-called 
obstruction atelectasis, and if pneumonitis is not developed, the oc- 
cluded sector undergoes "collapse induration," while the surrounding 
lung tissue becomes emphysematous. 

The clinical picture varies with the seat of the foreign body. 

In the lar^Tix, the invader provokes a stormy attack of coughing 
attended with a feeling of strangulation, cyanosis of the face, anxious 
expression of countenance and aphonia. After a time, this occurs in 
paroxyms with intervals of comparative quiescence. During the 
quiescent period, respiration is more or less embarrassed. The ex- 
pectoration is at first bloody, and later purulent in character. 

"When a foreign body gains access to the trachea and bronchi, the 
picture depends upon whether the invader is movable or immovable. 
Of the subjective sjinptoms, dyspnea is the most marked. Physical 
signs are of the greatest value. At times the palpating finger discovers 
the foreign body in the trachea or the stethoscope reveals a fluttering 
sound (grelottement of Dupuytren) in this situation. If the greater 
part of a bronchus is occluded, the respiratory murmur of the lung 
supplied by it is diminished or absent. The respiratory excursions of 
the affected side of the thorax are diminished; vocal fremitus is 
lessened ("Weist*). 

The diagnosis is based on the history of the case, the physical signs, 
and the findings of the laryngoscapic mirror and direct laryngoscopy. 
Of these, the latter, under chloroform narcosis, is the most reliable. 
In addition to this, the Rontgenographic negative is an exceedingly 
valuable aid (Fig. 824). Its value, of course, is dependent upon the 



1730 



SURGERY OF THE NECK 



character of the foreign bod}'; however, even though the object is 
not reproduced, the changes in the outline of the hings, as seen on 
the negative, are of diagnostic value. 

The pro(jnosis may be said to be very unfavorable, unless the for- 
eign body is removed, and is worse the longer this is postponed. 

In the treatment, irrespective of the views of the individual sur- 




FlG. 824. — EOXTGENOGRAM OF A FOREIGN BoDY (TACK) IX THE ElGHT BeONCHUS 

(Harlem Hospital case). 

geon, none will deny the imperative necessity for tracheotomy when 
<^leath from strangulation is threatened. The exception to this is when 
a foreign body is located at the entrance to the lar^Tix and can be 
reached with the finger. The expectant plan of treatment is to be 
condemned ; the use of emetics is of doubtful value. If the condition 
of the patient permits, an effort may be made to locate the offending 
agent with the mirror and to extract it with suitably fashioned forceps ; 



FOKEiliX UUDiES IX THE AiK I'ASSACiEb 17;J1 

failing in this direct lari/ngoscopy, tracheolontij and hronchoscopij 
are taken into consideration. 

The indications for tracheotomy in connection with deeply located 
foreign bodies have been somewhat restricted b}' the advent of the 
bronchoscope. Killian'' regards the indications for tracheotomy as 
being when great dyspnea exists, when lung complications have de- 
veloped, when the foreign body is large and so fashioned that its re- 
moval through the mouth would be likely to do damage, and when 
the invader consists of a substance likely to swell and become impacted 
(bean). The presence in the trachea of a fluttering object is an indi- 
cation for immediate tracheotomy. On the other hand, the technic 
of bronchoscopy is by no means eas}-; the ''opportunity broncho- 
scopist" is a dangerous person. Foreign bodies located in the larynx 
should be removed by iracheotomij; if the body is impacted, laryngo- 
iomy should be practiced. Suhhyaid pharyuyoiomy possesses no ad- 
vantage over the latter. Tracheotomy should also be employed for the 
removal of foreign bodies located in the trachea, unless the conditions 
are particularly favorable to rapid and skillful emplo^-ment of the 
bronchoscope. 

Bronchoscopy finds its greatest field of usefulness when the foreign 
body is located at or below the bifurcation of the trachea. For the 
purpose, the universal electroscope of Briinings (Fig. 823) is largely 
used to locate the invader and a number of ingenious forceps and 
snares are employed to effect the extraction. These are too numerous 
to describe here. 

In 1913 Mann*' of Dresden said "The first book regarding tracheo- 
bronchoscopy, in the English language, originated with Chevalier 
Jackson'^ of Philadelphia. In this the specialty received the impress 
of the individual. The inventive spirit of the American and his great 
personal independence, which knows not inrare in vcrha nmgistr.i, may 
be the reason for the improvements in technic which emanate from 
his country." Almost a prophecy. 

The complicated transmediastinal bronchotomies performed so far 
have not given encouraging results. 

BIBLIOGRAPHY 

1. V. Bruns and v. Hofmeister, in Handb. d. prakt. Chir. ii, Stuttgart, 1913. 

2. Heller. Quoted bj' No. 1. 

3. GoTTSTEix. Mitt. a. d. Grenzsreb., 1907, iii. 

4. Weist. Trans. Amer. Sure. Assoc, 1883 f collection of 1000 rases). 

5. KiLLiAX. Miinch. med. Woch., 1898, No. 27. 

fi. :\rAXV. Handb. d. spec. Cliir. d. Ohres, etc., ii, Wiirtzlmrir. 1913. 
7. Chevalier Jacksox. Tracheo-Bronchoscopy, Pittsburg, 1904. 



CHAPTER VIII 

INrLAMMATORY DISEASES, STENOSES AND NEUROSES OF THE 
LARYNX AND TRACHEA 

In inflammatory diseases of the air passages the function of the 
surgeon consists in the maintenance of the passage of air to the lungs 
rather than the treatment of the disease itself; the latter belongs to 
the internist and the laryngologist. Of the diseases belonging to this 
class, diphtheria is the most important; although this has already 
been extensively discussed (Part II, chap, xvi), the purely surgical 
aspects of the problem are still to be taken up. 

"While stenosis of the larynx is the chief symptom, in itself plead- 
ing, piteously enough, for tracheotomy, there is also no doubt that the 
incision has a favorable influence upon the circulatory disturbances 
coincident to the disease and that it is a valuable prophylactic 
MEASURE AGAINST BRONCHOPNEUMONiTis (Rauchfuss^) . If tracheotomy 
is postponed until respiratory embarrassment is menacing, the prog- 
nosis is much more unfavorable (Kronlein^). 

A discussion of the relative merits of tracheotomy and intubation does 
not belong here. The conclusions in this connection seem to be that the 
latter method has certain serious objections in diphtheria, the chief 
one being that an already infected mucosa is additionally damaged. 
In the hands of the trained operator the technic of intubation is not 
difficult ; however, extraction of the tube is not so readily accomplished. 
The instrumentarium is depicted in figure 825. 

Intubation of the larynx by the 'Dwyer method may be described 
as follows : The child is seated on the lap of the nurse ; an assistant 
steadies the head and slightly extends it ; the mouth is held open by the 
gag ; the left index finger pulls the epiglottis and the base of the tongue 
forward ; the cannula is passed along the posterior surface of the epi- 
glottis ; the introducer is withdrawn while the finger prevents with- 
drawal of the cannula. The safety string is either removed or fastened 
to the patient's ear. The introduction of the extubator is carried out 
in the same way. In infants the tube may often be expressed by 
making upward pressure on the external surface of the larynx. 

1732 



DISEASES OP THE LARYNX AND TRACHEA 1733 

Edema Laryngis ; Laryngitis Submucosa. — Edema of the larynx is 
most often the outcome of an inflammatory process. Differentiation be- 
tween an edema appearing as a part of general disturbances, such as 
anasarca or the result of venous stasis (tumors of the nock and medias- 
tinum), and that which is the result of a genuine inflammatory pro- 
cess is not always possible from a clinical standpoint. However, the 
latter form of the affection is more properly designated as laryngitis 
submucosa (Kiittner^). While several more or less complicated classi- 




FiG. 825. — O 'DwYER 's Intubation Set. 



fications of the processes have been submitted, that of Hajek* is the 
most simple and is based on its etiology as follows: (1) Those occur- 
ing in connection with local affections of the larynx and its vicinity, 
i. e., symptomatic and extension edema; and (2) infectious edema 
w^hich develops primaril}^ in the submucosa of the larynx or occurs in 
the course of an acute infectious disease. 

The first group includes submucous inflammations, already taken up 
in connection with injuries, foreign bodies, chemical and thermal influ- 



1734 SURGERY OF THE NECK 

ences, diphtheria, and the various infections of the pharynx, tonsils, 
palate, etc. 

The second group encompasses septicopyemic general infections, 
such as ulcerative endocarditis, erysipelas, t.vphus, variola, scarlatina, 
etc. It is probable that submucous laryngitis may be-due to extension 
of an erysipelatous process from the face. 

The submucous swelling may involve the entire larynx or may be 
limited to certain sectors. It does not present any regional peculari- 
ties and is of special importance only because it obstructs breathing. 
Abscess formation involves the danger of sudden death by strangula- 
tion. ..; 

Of the symptoms. pi edema of the glottis, interference with the pass- 
age of air to the liiijgs is the most important, especially since this is 
likely to develop W^th great rapidit3^ The greatest difficulty occurs 
during inspiration,? the result of the valvular action of the swollen 
arytenoid folds. The interference with vocalization is not character- 
istic. The most rapidly developing form of the aflfliction occurs in 
connection with er^^sipelatous and acute infectious phlegmon (Ger- 
ber^). -^ 

The diagnosis of gdema of the larynx is easily made with the mirror ; 
however, extensive 'swelling of the aryepiglottic folds often obscures 
the view into the larynx itself. Under no circumstances must efiPorts to 
visualize intralaryngeal swelling be attended with ungentle manipula- 
tions. As- a rule, the diagnosis may be based on the history of the case 
and, if this is not obtainable, an exact conclusion in this connection 
may very properly be postponed until the dyspnea is relieved. 

The treatment is primarily directed toward preventing the edema in 
cases in which this complication is likely to occur. Of these, the 
swallowing of particles of ice is of great benefit. Astringents should 
be avoided. The dominant indication in the problem is the mainten- 
ance of the free passage of air into the lungs. This is of course best 
established by prompt tracheoiomy which, after all, is the only meas- 
ure capable of defeating what v. Ziemssen,'' back in 1876, called "this 
perfidious affliction." 

In cases of stenosing laryngeal catarrh in children (pseudo croup), 
the use of O'Dwyer's intubation method may be regarded as distinctly 
indicated. 

Laryngeal Perichondritis. — Inflammation of the laryngeal peri- 
chondrium is usually secondary and occurs in connection with ulcera- 
tive processes of the mucosa (tuberculosis, lues, typhoid, variola, earci- 



DISEASES OF THE LARYNX AND TRACHEA 1735 

noma, etc.) which aUow of the ])a.ssage oL' i)yogeiiic bacteria, or the 
process is metastatic in the course of general infections (scarlatina, 
typhoid fever, etc.). Perichondritis also develops after trauma to the 
interior of the larj-nx (foreign bodies, chemical burns, etc.). Pj^imary 
perichondritis is a terra applied to those cases in which the port of 
entrance of the provocative influence is not discoverable. The anato^ 
niical changes are similar to those taken up in connection with peri- 
chondritis and periostitis (Part II, chap. x). Of the various parts 
of the larynx, the arytenoid cartilages are most often affected. Simi- 
lar processes occur in the trachea, but they are rare. 

The dangers of perichondritis of the larynx consist in mechanical 
obstruction to respiration, either from the inflammation or from col- 
lateral edema. Asphyxiation from the incarceration of a loosened se- 
questrum has occurred. Secondary stenosis and permanent fixation 
of the vocal cords, the result of sequential cicatrical contracture, is not 
uncommon. 

Painful deglutition, hoarseness and dyspnea are the chief s]jnipton\s. 
However, the diagnosis must be established by laryngological exami- 
nation and the symptoms of inflammation. 

The treatment is similar to that used in connection with inflamma- 
tions in general. The indication for tracheotomy rests on the degree 
of dyspnea; it should not be dela3^ed. Incision of perichondritis ex- 
terna is of course accomplished from without. Endolaryngcal incision 
of processes bulging into the lar>^nx is a difScult maneuver unless the 
abscess is located very high up. On general principles, these should 
also be opened from the neck. As in all affections of this nature, a 
policy of timidity is to be deprecated. Laryngotomy and the establish- 
ment of drainage, wnth the bronchi protected by a tracheotomy tube, 
gives the best results. 

Specific Inflammations of the Larynx and Trachea. — The primary and 
secondary chronic inflammatory lesions of the larynx and trachea nsu- 
aWy are either* tuberculous or luetic in nature. A few of the cases are 
due to the persistence of a so-called catarrhal inflammatioi;!, which no 
doubt is also infectious in character; the precise nature of this infec- 
tion is not known. These have been burdened with a number of 
names, such as chord itis vocalis inferior h upertrophica, hlennorrhea, 
lar\jngoscJcron\a, etc. 

Tuberculosis. — Tuherculosis of the larijnx alone is very rare ; in the 
vast majority of cases it is secondary to a similar lesion situated else- 
where in the body, usually the lung. 



1736 SURGERY OF THE NECK 

The character of the lesion does not differ from those located else- 
where in the body. The vocal cords and the posterior wall of the 
larynx are at first involved. The fact that the cord first affected cor- 
responds to the invaded lung is worthy of note. The process becomes 
of surgical importance when it is attended with deep ulceration, 
invasion of the perichondium and edema. 

Tuberculosis of the trachea occurs in one half of the autopsied cases 
of larj'ngeal tuberculosis. 

The diagnosis is based on dysphagia, aphonia, cough and pain (the 
last is likely to be severe), together with the laryngological findings; 
however, it is only certain when the bacilli are found in a smear taken 
from the lesion. The coexistence of tuberculosis and syphilis in this 
situation is not infrequent. The prognosis is unfavorable, the fatal out- 
come being ascribable to the underlying condition (lung). 

The surgical treatment consists in the local application of anodynes 
(anesthesin, orthoform, alypin). The injection into the superior laryn- 
geal nerve of 85 per cent alcohol produces anesthesia of the larjmx 
for from six to forty days and is a justifiable measure of relief. Severe 
dysphagia justifies gastrostomy. 

Direct attack by the external route brings the affliction into the 
domain of the general surgeon. Endolaryngeal operative m,easures are 
not often productive of satisfactory results. Tracheotomy is indicated 
when edema causes menacing obstruction. Laryngectomy (complete or 
incomplete) is a bold undertaking; however, complete recovery fol- 
lowed in four of twenty cases operated upon by Gluck^. Laryngo- 
fissure and excision of the lesion has been practiced more than one 
hundred times. The local recovery has been much shadowed by the 
ultimate domination of the lung condition. The cases in which the 
procedure is permissable must be carefully selected. Exacerbation of 
the process in the lung has been frequently observed. 

Lupus of the larynx occurs in the form of nodular and papillomatous 
excrescences. It is likely to simulate lues and lepra in this situation 
(Mayer^). 

Syphilis. — Lues of the larynx appears at all periods of the general 
disease and occurs in 10 per cent of the cases (Gerhardt"). The 
ulcerative form is ascribed to disintegrated gummatous infiltration. 
This usually denudes the perichondrium and at times destroys the 
cartilage. Healing is attended with cicratricial stenoses. 

In the diagnosis, tuberculosis and carcinoma must be considered. 
One must bear in mind that two of these may be present in the same 



DISEASES OF THE LARYNX AND TRACHEA 1737 

imlividual. The therapeutic test is of some value in cases of this sort. 
In extensive lesions ("tlorid lues") emei-gcncy tracheotomy may be- 
come necessary. During repair the careful use of the bougie may 
obviate laryngeal stenosis. For the general treatment see Part II, 
chap. XXV. 

Actinonijjcosis of the larynx has been found to be more frequent 
since tlie advent of the more general employment of the microscope in 
arriving at a conclusion in regard to the exact nature of chronic 
inflammatory conditions in the upper air passages. As a rule, the 
invasion of the lar^^nx by the process is secondary to a lesion of the 
neighboring parts. Primary actinomj^cosis of the larynx does not 
seem to have been reported as yet (Henrici^°). The treatment is 
similar to that employed in actinomycosis located elsewhere in the 
body. The local injection of bichlorid of mercury solution seems to be 
of benefit. 

Scleroma of the larynx is rarely primary (see Part II, chap, xxvi ; 
also Pieuiazek,^^ and v. Riidiger-Rj^dygier^^). 

Stenoses of the Larynx and Trachea. — Stenoses of the larynx occur 
in connection with a number of pathological processes in this situation ; 
the}^ ma}^ be divided into temporary and perma^ient. The former have 
already been considered. 

The etiology of permanent stenosis of the larynx has been discussed 
in connection with the pathological processes occurring in this situa- 
tion. Almost all of these may be responsible for narrowing of the 
lumen of the larynx, while a few are always followed by it. Of the 
causative lesions, those occurring in connection with inquiries, tertiary 
lues, and perichmidritis are the most frequent offenders. Perichon- 
dritis is most likely to be followed by stenosis when the former de- 
velops in the course of acute infectious diseases, such as typhoid, scar- 
latina, and variola, in the order mentioned. Late stenoses, following 
diphtheria, are due to trauma caused by intubation and tracheotomy, 
although the obstruction following the latter is located in the trachea. 
Narrowing of the lumen of the larynx, sequential to intubation, is 
especially obstinate in character. 

The form of the stenosis varies with its cause, the diaphragmatic and 
funnel shaped strictures being the most frequent, although the cyliii- 
dj'ical form is not by any means rare. 

Dyspnea and stridor are the cardinal symptoms of laryngeal stenosis 
and are manifested in proportion to the degree of the obstruction. It 
is astonishing how narrow an orifice will permit of the passage of suffi- 



1738 



SURGERY OF THE NECK 



cient air to maintain life, especially if the obstruction develops gradu- 
ally. 

The immediate indication in the treatment calls for tracheotomy; 
this must not be postponed until the danger of strangulation becomes 
imminent. 

The measures employed f(»r the purpose of overcoming the stricture 
may be stated as follows: 

1. Intralaryngeal dilation without tracheotomy. 

2. Dilation after tracheotomy, 
using the wound as a means of ap- 
proaching the stricture. 

3. Laryngotomy. 

4. Resection of the larynx. 
Dilation may be assisted by endo- 

laryngeal discission of the stric- 
ture; this is especially applicable 
when the latter consists of a thin 
membrane. The extralarj^ngeal 
methods must always be followed 
b}' a more or less prolonged use of 
dilators (Rosenberg"). When a 
tracheotomy ivound is present the 
dilators maj be passed from below 
and withdrawn from the mouth. In 
these cases hollow dilators may be 
left in situ for varying periods of 
time. 

Laryngofissure is employed for 
the purpose of introducing dilat- 
ing apparatus (T-cannula, chim- 
ney cannula, etc.)., or to permit 
of the excision of cicatrical tis- 
sue. By this method of approach suh perichondral resection of 
the cartilage of the larjmx may be performed. In recent years a 
laryngotomy is first performed and the fistula is used for subse- 
quent dilation of the stricture. In this method the opened larynx 
is fastened to the skin, which permits of the use of variously shaped 
dilators; these may be left in situ for days at a time (Sargnon 
et Barlatier"). The fi.stula is ultimately closed by means of a flap. 




Fig. 826. — Cicatricial Stenosis op 
THE Larynx Following Suicide 
Wound (viewed from behind). 



DISEASES OF THE LARYNX AND TRACHEA 1739 

Gluck^' excises the stricture and turns two skin flaps into the larynx. 
The dihitation method must be persisted in for months. 

Dilatation in connection with tracheotomy permits of retention of 
the dilator without danger of sutfocation, and in most cases will be 
found a satisfactory method. In the hands of the trained, technician 
laryngo fissure and excision of the stricture and plastic repair give 
the most brilliant results. 

Stenoses of the trachea are often caused by extramural pressure, of 
which enlai'gement of the thyroid gland is not the least important. 
The intratracheal causes of stenosis (exclusive of those provoked by 
a tracheotomy' tube) are similar to those operative within the larynx, 
and, of these, lues again plays the leading role. 

The general symptoms of tracheal stenosis do not differ from those 
of laryngeal obstruction. The diagnosis will have to rest very largely 
upon the history of the case, and of course direct bronchoscopy will 
make it certain. The Rontgenogram is of great assistance. Rethi^® 
introduces a photographic film into the esophagus and obtains remark- 
ably clear shadows of the trachea. 

The treatment in many respects is similar to that discussed in 
connection W'ith the larynx. Low obstructions are reached with 
specially constructed instruments introduced through a tracheotomy 
wound. Sectional resection of the stenosed area and end to end suture 
is permissible in selected cases (v. Eiselsberg^^). 

Fistulae of the Larynx and Trachea. — Fistulae of the lar^mx and 
trachea are the result of injury and of necrosis. Those of the latter 
class are subdivided into ulcerative and cicatricial. 

Ulcerative fistulae follow suppurative perichondritis, diphtheria, 
carcinoma, etc. Cicatricial fistulae appear in connection with ulcera- 
tive processes (other than carcinoma) which do not entirely heal, and 
when the mucosa becomes adherent to the skin. Either form of 
fistula may be located in any of the areas of the larjTix or trachea. 
In the cicatricial form the fistula usually corresponds to the point of 
greatest stenosis. 

The external skin is usually drawn inward in the form of a funnel, 
at the apex of which the opening in the trachea is visible. If stenosis 
is located above the fistula, closure of the latter must not be attempted. 

The significance of an air fistula depends upon its size. The 
smaller ones are simply an annoyance, while the larger, if associated 
with stenosis, condemn the patient to the perpetual use of a cannula. 

An air fistula is often associated with an esophageal opening in cases 



1740 SURGERY OF THE NECK 

of severe injury in this location, especially after transverse section of 
the upper trachea and esophagus. However, persistence of the eso- 
phageal opening is rare. 

The disturbances caused by a communication between the trachea 
and osephagus relate especially to the entrance of food into the former. 
The diagnosis is easily verified with the esophagobronchoscope. 

Closure of an air fistula is permissible onhj in the absence of stenosis 
of the air passage. The operative methods of relief are grouped under 
the name of bronchoplasty. Small fistulae may be closed by the use of 
the cautery and a purse string suture, or complete excision and repair 
by suture may be practiced. The larger ones must be closed by plastic 
methods. A free skin periosteal flap, taken from the sternum, was 
successfully implanted by Schimmelbusch.^* Photiades and Lardy^'' 
used a pedunculated flap from the clavicle. A tracheal fistula may be 
closed by a cartilage flap turned down from the lar\Tix (Koenig-*'). 

The neuroses of the larynx pos-sess surgical importance only when 
bilateral paralysis of the vocal cords is attended with obstruction to 
breathing. In these instances tracheotomy is imperative. 

BIBLIOGRAPHY 

1. Rauchfuss. Gerhardt's Handb. d. Kinderlieilk, iii. 

2. Kroxleix. Arch. f. klin. Chir. xxi. 

3. KuTTX'^ER. Larynxoderaa and submucous Larj'ngitis, Berlin, 1895. 

4. Hajek. Heymann's Handb. d. laryn., etc., i. 

5. Gerber. Quoted by Xo. 4. 

6. V. ZiEMSSEX. Hanclb. d. spec. Path., etc., 1876. 

7. Gluck. Quoted bv v. Bnins-v. Hofmeister, Handb. d. prakt. Chir., 

Stutto-art, 1913^ ii. 

8. Mater. X. Y. Med. Jr., 1898. 

9. Gerhardt. Same as No. 4. 

10. Hexrici. Arch. f. Larvn. xiv. 

11. PiEXiAZEK. Same as No. 4. 

12. V. Ri'DiGER-RymTiiER. Zentrbl. f. Chir., 1911, No. 35. 

13. RosEXBERG. He\Tnann's Handb. d. Laryn., etc., i, with com. lit. 

14. Sargxox et Barlatier. Presse med., 1908, and Semaine med., 1909. 

15. Gluck. Thorst, Die Yerene. d. obern. luftweee, Berlin, 1911. 

16. Rethi. Deutsch. med. TYoch., 1912, No. 14. 

17. V. Eiselsberg. Deutsch. med. "Woch., 1896. 

18. ScHiMMELEUSCH. Verb. Deutsch. Gesel. f. Chir., 1893. 

19. Photiades et Lardt. Rev. med. de la Suisse, rem 1893, No. 1. 

20. KOEXiG. Berlin, klin. Woeh., 1896, No. 1. 



CHAPTER IX 

TUMOES OF THE LARYNX, TRACHEA, AND PRIMARY BRONCHI 

Most of the tumors of the interior of the larynx and trachea belong 
to the domain of huyngoscopie surgery, which has accomplished much 
in this connection. Wliile this is true of the majority of benign tumors, 
it is also true that the probh^ms connected with malignant tumors be- 
long to the field of general surger3^ The subject will therefore be 
taken up from this standpoint. 

Benign Tumors of the Larynx. — Fibromata and papillomata are the 
tumors most frequently found in the larynx. In 370 cases, 55 per 
cent were fibromata and 35 per cent papillomata (v. Bruns'^), 

Fihromata develop in the submucosa and vary in size from a pea to 
a cherry. They are smooth (occasionally nodular), have a wnde base, 
are dark red in color, and are usually located at the anterior edge of 
the vocal cords. They develop late in life, 

Papillomata appear in the form of warts or berries, and at times 
resemble the slender condylomata of the skin. Collections of a num- 
ber of these growths take on peculiar forms. They are red in color 
and, when covered with horny epithelium, may be gray. 

The importance of papillomata lies in the fact that they appear 
early in life and are likely to undergo malignant changes (carci- 
noma). 

Cystic tumors of the larynx are very rare (4 per cent). Myxomata, 
angiomata, and lymph angiomata are also uncommon (Chiari^). Lipo- 
mata may reach a large size. As is to be expected, chondromata are 
not so rare ; however, they are by no means common. 

The symptoms of benign tumors of the larynx depend upon their 
size and location. Most of them are situated upon the vocal cords, 
including the anterior commissure. Of 1,000 cases seen by v. Bruns,^ 
72 per cent showed modification of the voice. Aside from this, a 
number of small tumors of the vocal cords simply cause modification of 
the singing voice C singer's nodules"). The degree of interference 
with respiration depends of course upon the volume of the growth; 

1741 



1742 



SURGERY OF THE NECK 



it is not often great. Pedunculated tumors interfere with function 
intermittently. 

The diagnosis can be made with certainty only by laryngoscopic ex- 
amination, which determines the presence, extent, and often the char- 
acter of the growth. However, the latter must be verified b.y means of 
the microscope. 

Extirpation of henign tumors may often be accomplished by the 
endolaryngeal route; in a certain 
number of cases, laryngofissure 
is necessary. Execution of the 
former methods means special 
apparatus and considerable tech- 
nical skill ; it is quite restricted 
to the larj'ngologist. The em- 
ployment of the direct method 
has made removal of heretofore 
inaccessible tumors possible and 
has the additional advantage of 
permitting general narcosis. 
Preliminary exposure by laryn- 
gofissure is indicated when the 
growth is attached by a broad 
base and is of large dimensions, 
or when a large number of 
papillomata are present. Partial 
laryngotomy, below the vocal 
cords, is desirable when the 
seat of the growth justifies 
its employment. Suhhy aid 
pharyngotomy gives excellent 
access to the upper sectors of the 
larynx. 

Malignant Tumors of the Larynx. — Of the malignant tumors of the 
larynx, sarcoma, compared to carcinoma, occurs once in twelve cases. 

Sarcoma of the larynx is essentially a disease of earlj^ life. In 
1908 Hiltermann^ presented a statistical study of 125 cases of primary 
and 17 cases of secondary sarcoma of the larynx. The tumor is usu- 
ally situated at the vocal cords and shows little tendency to break 
down. It appears in the form of a sharply defined, hard, light red 
mass with a smooth surface, and usually is attached by a broad base. 




Fig. 827.- 



MuLTiPLK Papillomata of 
THE Larnyx. 



TUMORS OF THE LARYNX AND TRACHEA 1743 

It grows very rapidly, soon reaching the size of a walnut; however, 
its extension is limited to the soft parts, and erosion of the cartilage 
is rare. Lymphatic invasion occurs late and may be absent. Of the 
various forms of sarcoma, the spindle cell, which originates in sub- 
mucosa, is the one most commonly found. 

The di(ig)wsis is not oas}^ especially as the growth at first bears 
considerable resemblance to a benign tumor. Microscopical examina- 
tion of a section removed by the endolaryngeal method clears up the 
problem. 

The treatment is limited to complete laryngectomy. Despite this 
radical measure, the process recurs in 80 per cent of the cases. 

Carcinoma of the larynx occurs in the last half of life. Eighty-four 
per cent of the cases occur in persons moi-e than forty years of age. 
It appears in all portions of the larynx; however, the rim of the 
thyroid cartilage (epiglottis) is most often affected. Pavement cell 
carcinoma is the most common form in which the process appears; 
adenocarcinoma is rare. 

In the early stages^ the disease appears in the form of a circuni- 
scrihed infiltrate of the mucous membrane, wlxich is flat or slightly 
elevated, or it presents the appearance of a warty excrescence. This 
condition of affairs may persist for several years. 

In the advanced stage of the process the growth ulcerates and in- 
vades the contiguous tissues, losing its circumscribed character and 
being surrounded by an area of edematous swelling. The process now 
corresponds in every regard to that described in connection with 
carcinomata of mucous membranes (Part VI, chap. xvii). Invasion 
of the neighhoring lymph nodes is not constant and appears late in the 
process, especiall}" in the essentially endolaryngeal growths. Metas- 
tases are uncommon ; however, the writer has seen vertebral foci in 
two cases in which laryngectomy has been performed. 

Secondary carcinoyna of the larynx is rare ; on the other hand, it is 
often invaded hj extension from neighboring parts. 

The clinical picture of carcinoma of the larynx in its early stages 
varies with its location. When the region of the epiglottis is involved, 
hoarseness is a dominant symptom, v. Bruns^ says "Persistent 

HOARSENESS WITHOUT COUGH IN MIDDLE AGED MEN DEMANDS A LARYN- 

Goscopic EXAMINATION." The impairment of the voice is progressive 
and ultimatelj^ ends in aphonia. The latter is due to impairment of 
the vocal cords and to pressure on the motor nerves. So-called extrin- 
sic cancer is heralded by dysphagia, which is progressive and may make 



1744 SURGERY OF THE NECK 

deglutition impossible. As the lesion progresses, dyspnea develops to 
a lesser or greater degree. Pain is always present. Later in. the 
disease, bloody expectoration appears. Cachexia presents itself late. 

The diagnosis is difficult in the early stages of the disease ; it may 
then be established by the employment of all the accessory aids. These 
must assist in differentiating the lesion from lues, tuberculosis, acti- 
nomycosis, and benign tumors. One must remember that the last often 
become carcinomatous, especially papillomata. To the laryngologist, 
rigidity of the affected vocal cord is a suspicious sign. As to the 
extent of the lesion, the mirror is a deceitful helper, direct laryngo- 
scopy is less so. Of course the microscopical fielding should decide the 
question ; however, Semon,* who warns us that this must be in accord 
with the clinical picture, states that of 246 cases observ^ed in private 
practice, he failed to recognize carcinoma in fifteen. He furnishes an 
instructive resume in this connection. 

The prognosis, until thirty years ago, was very unfavorable arid only 
comparatively better for the following twenty years. The improve- 
ment in the last ten years is the outcome of more exact diagnostic 
methods and the technic of the radical operation. The fact that endo- 
laryngeal carcinoma is not attended with involvement of the lymph 
nodes early in the disease makes the prognosis less unfavorable in this 
class of cases. 

The radical measures of relief may be stated as follows: 

1. Endolaryngeal extirpation. 

2. Extirpation via thyroidotomy. 

3. Extirpation via subhyoid pliaryngotomy. 

4. Partial extirpation of the larynx. 

5. Total laryngectomy. 

1. Endolaryngeal total extirpation of carcinoma is possible, but 
may be said to be "taking an unwarranted risk," a view shared by 
most laryngologists of note. 

2. Thyroidotomy, or laryngofissure, is the normal procedure in the 
early stages of endolaryngeal carcinoma. The mortality is 10 per 
cent (Bryson Delevan,^ Santi,^ Molinie''). 

3. Subhyoid pharyngotomy is used only when the disease is located 
at the epiglottis and the aryepiglottic folds — so-called extralaryngeal 
carcinoma. The mortalitj^ is 40 per cent (Jurasz^). 

4. Partial laryngectomy is indicated when the disease is limited to 
one side of the larynx (Gluck^) . It has a restricted fi.eld of application, 
and a mortality of 26 per cent (v. Bruns^). 



TUMORS OF THE LARYNX AND TRACHEA 1745 



5. 'Total lanjngectonnj is indicated in cases in which partial ex- 
tirpation is not. It is also performed as a part of the procedure when 
the disease has extended to the pharynx and esophagus. The operation 
achieves its most brilliant possibilities in cases of endolaryngeal car- 
cinoma. It has a mortality of 22 per cent (v. Bruns^). The writer 
performs total laryngectomy as soon as the diagnosis is made. 

Tumors of the Trachea. — Compared to tumors of the larynx, those of 
the trachea are rare ; however, the advent of direct tracheoscopy has 
markedly lessened this diflference. 

Benign Tumors. — Of the benign tumors, fibromata and papillo- 

mata are the most common. 
Osteochondromata, as is to be 
expected, have also appeared in 
this situation (Thiesen^°). 

The symptomatology of be- 
nign tumors of the trachea may 
be encompassed within the clini- 
cal picture of obstruction to 
respiration, which is very grad- 
ual in its onset (Gerhardt^^). 

The diagnosis must exclude 
pressure on the trachea from 
without. In most instances the 
growth may be visualized by 
direct bronchoscopy. 

The operative treatment has 
a number of brilliant results to 
its credit. The palliative treat- 
ment consists in providing a pas- 
sage for air. This may be accom- 
plished by low tracheotomy and the introduction of a long pliable tube. 
Extirpation of the growth has frequently been accomplished through 
the bronchoscope, either directly or through a tracheotomy wound. 
The latter is the better method. V. Bruns^ reports nine successful 
cases of this sort. 

Malignant Tumors. — Malignant tumors of the trachea are not as 
rare as are the benign. 

Primary sarcomata of the trachea are usually a part of a growth 
extending from the lower posterior portion of the larynx ; most of them 
are spindle cell. Although a growth of this sort has occasionally been 




Fig. 828. — Lipoma of the Left 
Bronchus. 



1746 SURGERY OF THE NECK 

removed through the larynx, approach by means of a tracheotomy 
wound best accomplishes the purpose. 

Carcinoma of the trachea is more frequent than sarcoma, and usu- 
ally involves the posterior, lower portion. The diagnosis is made by 
means of direct tracheoscopy. The outlook is unfavorable; however, 
resection of the affected portion of the trachea and end to end anasto- 
mosis has been successfull}^ performed in several instances (v. Bruns^). 

Tumors of the Primary Bronchi. — Exploration of the bronchi is so 
recent a measure that recognition of new growths in this situation is 
as yet restricted to a narrow field. V. Bruns^ has collected seventy- 
five cases of tumors of the bronchi revealed b}'- the bronchoscope. Of 
these, 36 were benign, 35 malignant, and 4 of unknown nature. 

The diagnosis is of course possible only by means of the broncho- 
scope. This rather difficult examination is justified in the event of 
persistent cough and dyspnea, not explainable on the basis of the 
other numerous factors which are also responsible for these disturb- 
ances. There is no doubt that, were the possibilit.y of a bronchial tumor 
more often taken into account, the number of cases would be consider- 
ably increased. 

BIBLIOGRAPHY 

1. V. Bruns. Handb. d. prakt. Chir. ii, Stuttgart, 1913. 

2. Chiari. Arch. f. Laryngol. viii. 

3. HiLTERMANN, Beitr. z. kasuistik. d. Larynx Sareome, Mlinch., 1908. 

4. Semok. Lancet, 1904. 

5. Bryson Delavan. Trans. Am. Laryn. Assoc, 1900. 

6. Santi. Malignant Disease of the Larynx, London, 1904. 

7. MoLixiB. Tumeurs malig. d. larynx., Paris, 1907. 

8. JuRASZ. Heymann's Handb. d. Laryng., etc., i, with comp. lit. 

9. (tLUCK. Jahreskurse f. Arzt. Fortbildung, 1912. 

10. Thiesen. Amer. Laryng. Assoc, 1906. 

11. Gerhardt, See Bibliography of No. 8. 



CHAPTER X 
OPERATIONS ON THE AIR PASSAGES 

Tracheotomy. — Tn a general way tracheotomy is employed for two 
purposes — the establishment of a free passage of air to the 
LUNGS and to provide access to the region below the glottis. 

The special indications are as follows: 

1. Injuries of the larynx and trachea. 



Foreign bodies in the air passages. 

Acute inflammatory processes in the larynx and trachea. 

Chronic inflammatorj^ processes. 

Compression stenoses. 

Neuroses. 

Tumors of the larynx and trachea. 

Preliminarj' tracheotomy in connection with operations on the 
upper air passages. 

To these may be added the necessity for the measure in cases of 
asphyxia due to the inspiration of gasses and chloroform. 

In the techmc of tracheotomy it is necessary to take into account 
certain anatomical considerations. While the cricoid cartilage and the 
cricothyroid membrane do not actually belong to the trachea, they are 
included in the problem because of their frequent invasion when the 
trachea is opened. The trachea is superficially located at its upper 
aspect, but is gradually more deeply situated until at the episternal 
notch it is 3 cm. deeper than the skin. The cricoid ring is alwaj-s 
palpable. The isthmus of the thyroid gland divides the tracheotomy 
field into two sectors: unfortunately the variations in its diameter do 
not permit of an exact localization in this connection. In addition to 
this the p.vramidal lobe, which originates from the upper edge of the 
isthmus and extends upward, sometimes as high as the hyoid bone, must 
be taken into consideration. The pyramidal lobe is present in 74 per 
cent of the cases. The isthmus is held in contact with the trachea bj' a 
process of its own capsule (th^Tolaryngeal ligament), which splits into 
two layers and is attached to the cartilaginous rings below. The 

1747 



1748 SURGERY OF THE NECK 

cricothyroid artery (a branch of the superior thyroid) crosses the mem- 
brane of the same name ; below the isthmus a number of veins cross 
the trachea (plexus thyroideus impar) ; these communicate directly 
with the innominate vein. Occasionally the latter vessel and the artery 
obtrude into the episternal notch, hi children, the space between the 
isthmus and the episternal notch is as long as in the adult, while that 
between the former and the cricoid cartilage is only one centimeter. 
The space available for tracheotomy may be utilized as follows: 

1. Thyrocricotomy — section of the conoid ligament.. 

2. Cricotomy — section of the cricoid cartilage, together with crico- 
tracheotomy, in which one or more of the rings of the trachea are also 
divided. 

3. Superior tracheotomy — opening of the trachea above the 
thyroid isthmus. 

4. Median tracheotomy — section through the isthmus. 

5. Inferior tracheotomy — section in the space between the innomi- 
nate vein and the isthmus. From a practical standpoint, the opera- 
tion is performed either ahove or helow the isthmus. 

Cricotomy presents the least technical difficulties. 

The posture of the patient is important; the head is extended by 
placing a firm "roll" under the neck. Despite the prolonged discus- 
sion regarding the use of various anesthetics, this aspect of the prob- 
lem may be answered by the unqualified statement that nothing takes 
the place of the judicious administration of chloroform when dyspnea 
is present. In the absence of the later, local anesthesia may be used 
m the adult 

The incision is made in the median line and should be three or four 
centimeters in length ; in any event, it should be ample rather than the 
reverse. The subcutaneous veins are divided between forcipressure, 
which act as retractors until the median borders of the sternohyoid 
muscles (linea alba colli) are identified. The intermuscular space is 
opened and the muscles drawn apart with retractors. In this way, 
the isthmus and tracheal rings are exposed and the point at which the 
trachea is to be opened is decided upon. 

In superior tracheotomy, when the isthmus does not cover the upper 
end of the trachea, the deep fascia is opened in order to get the requisite 
room. If this is not the case (which is the rule), retrofascial separa- 
tion of the isthmus is proceeded with ; the thyrolar;\Tigeal fascia is di- 
vided transversely at the lower edge of the cricoid cartilage and it, 
together with the isthmus, is lifted from the trachea and pulled down- 



OPERATIONS ON THE AIR PASSAGES 



1749 



ward. If a pyramidal lobe is present, this is drawn down to either 
side or may be extirpated. 

In inferior tracheotomy the deep fascia of the neck is divided below 
the isthmus. In manipulating in the pretracheal fat, the disturbing 
proximity of the innominate vein must be given consideration. The 
isthmus is pulled upward and the veins, already spoken of, are avoided. 
The transverse veins are clamped, divided and ligated. 

Opening of the trachea must be postponed until bleeding is definitely 




'fyr:vJ ..^!t:Lije 



-. Vii^roid gLinci 



Pig. 829. — Tracheotomy. 
Showing spaces for various methods. Inferior tracheotomy completed. 



arrested. The trachea is steadied with tenaculae introduced at either 
side of the media line, the ithmus is held out of the way, and the knife, 
with its cutting edge turned toward the chin, is plunged into the 
trachea and the incision made to conform to the size of the cannula 
to be used. As a rule, the sudden inrush of air is immediately followed 
by a trief period of apnea, the outcome of a sudden diminution of car- 
bon dioxid in the medulla. The cannula is not introduced until 
RESPIRATION IS TRANQUIL. Frauck^ adviscs transverse division of the 



1750 



SURGERY OF THE NECK 



skin with the view of preventing scarring; this is its only advantage. 
Thost- advises excision of an elliptical sector of the trachea in order to 
obviate inversion of the tracheal rings. In 
tracheotomie dans un seul temps of St. Ger- 
main^ the operator grasps the larynx with 
the left hand and plunges the knife into the 
cricothyroid space, dividing the cricoid car- 
tilage and several rings of the trachea in 
one sweep. Its emplojTnent is justified only 
in cases of imminent strangulation. 

The selection of an appropriate cannula 
is of great importance. A description of 
the various cannulae exploited at different 

times would fill many pages. The writer still clings to the well known 
Luer double cannula fitted with a movable shield (Fig. 830) ; its curve 
corresponds to from one fifth to one fourth of a circle. The dimensions 
of a cannula suitable to the age of the patient are tabulated below: 




Fig. 830. — Luer's Double 
Cannula. 



Age 



11/2-2 yrs. 
2-4 yrs. . 
4-6 yrs. . 
6-8 yrs. . 
8-12 yrs. 
Adult. . .. 





Diam. of 


Lumen of 


Diam. of 


outer 


inner 


trachea 


cannula 


cannula 


mm. 


mm. 


mm. 


5-6 


.5.5 


4 


7 


6.5 


5 


8 


7.5 


6 


9 


8.5 


7 


10 


9.5 


8 


12-23 


11-13 


9-11 




and more 


and more 



Curve of cannula 
on concave 
side 
Short c. Long c. 



76 deg. 

81 deg. 
83 deg. 
85 deg. 

82 deg. 
81 deg. 



Ill deg. 

101 deg. 
96 deg. 

102 deg. 

103 deg. 
103 deg. 



Radius 

on the 

concave 

side 

mm. 



19 
21 
23 
24 
25 
29 



The dangers during the operation consist in bleeding, which is 
purely a matter of technic ; asphj-xia (see above), which usuallj'' bows 
to artificial respiration ; and decollement of the mucosa, which is 
avoided by proper introduction of the tube. 

The after treatment of the tracheotomized patient, especially in 
diphtheria cases, calls for constant care, so that the free passage of air 
is maintained. As soon as respiration is embarrassed, the inner tube 
must be removed and cleansed. The inspired air must be kept moist ; 
this is best accomplished by means of the "croup kettle." Decannule- 



OPERATIONS OX THE AIR PASSAGES 1751 

MEXT IS PERMISSIBLE AS SOOX AS THE LARYNX PERMITS THE FREE 
PASSAGE OF AIR. 

Decannulement is preceded by testing the patency of the larynx. 
For the purpose, the tracheotomy tube may be obstructed for increas- 
ing periods of time, until the patient sleeps the entire night with the 
tube occluded ; the inner tube may be removed and the extratracheal 
opening of the outer closed, so that the patient breathes through the 
window in the latter, or -a "weaning tube" may be used. The last 
consists of an ordinary tracheotomy tube of small size fitted with an 
obturator. If sufficient air passes the tube with the obturator in place, 
it may be safely removed. 

Decubitus from cannula pressure is a not uncommon sequel of 
tracheotomy. The pressure ulcer usually corresponds to the point 
where the lower end of the cannula lies in contact with the anterior 
wall of the trachea ; ulceration of the posterior wall, from pressure by 
the bow of the tube, is less frequent. Much of this may be prevented 
by the selection of a cannula suitable to the case (see table). The ad- 
vent of ulceration is heralded by pain, fever, and bloody expectorate. 

Secondary hemorrhage, excluding that from the operative wound — 
the outcome of injury to blood vessels — is due first to erosion of a 

VESSEL, THE RESULT OF INFECTION, and SeCOnd to NECROSIS OF THE WALLS 

OF A MISSEL FROM PRESSURE OF THE CANNULA. A Cannula lias causcd 
perforation into the innominate vein. 

Delay in decanntdement is productive of various forms of stenosis. 

Granulation stenosis takes its origin in the tracheal wound, usually 
at is upper angle. The granulations are especially prolific in the 
lar^Tix. Thost^ describes a condition of diffuse gramdation stenosis, 
in which the entire wound area and the contiguous trachea are invaded, 
and, in some instances, the cartilage is destroyed. Healing is followed 
by cicatricial contraction. The condition is ascribed to irritation from 
the tube and is more marked the higher the wound is located. 

The chief symptom of granuloma is dyspnea as soon as the tube is 
removed. The dia-gnosis is made certain by larjiigological exam- 
ination. 

The treatment of course takes prophylaxis into account. This 
means early decannulement. Removal of the granulation tissue is not 
easy. In cases of moderate degree, repeated cauterization or curette- 
ment accomplishes the purpose. TVhen the wound is closed the latter 
may be executed by the larjiigeal route. Retracheotomy is often 
necessary; this is followed by the more or less prolonged use of suit- 



1752 



SURGERY OF THE NECK 



ably fashioned tubes which make even pressure upon the granulations. 
The carefully adjusted employment of the 'Dwyer intubation method 
also achieves the desired end. 

Deformati&n stenosis is a term applied to obstruction of the trachea, 
the outcome of deformation of the tracheal wall by the pressure of the 
cannula. Figure 831 shows the various forms in which the obstruc- 
tion occurs and is quite explanatory in this connection. To clarify 
this still more, one may consider the trachea a semirigid tube suscep- 
tible to kinking and to various forms of mutilation, not the least fre- 
quent of which is the "incurving" of the edges of the tracheotomy 
wound. The ultimate outcome of this is stenosis of varj'ing severity. 
Early decannulement tends to prevent its occurrence. Once estab- 
lished, the treatment is carried out as already stated. 







Fig. 831. — Posttracheotomic Stenoses. 



Tamponade of the Trachea. — The use of the gauze pack for the 
purpose of obviating the flow of blood and secretions into the lower air 
passages during operations in these regions has been replaced by the 
combination of tampon and cannula. The apparatus consists of an 
ordinary cannula surrounded with a rubber condom which is distended 
with air by means of a hand bulb, thus effectually occluding the 
extracannular portion of the trachea (Trendelenburg*). The object 
may be attained by entwining the cannula with vegetable sponge or 
other material which swells when it absorbs moisture. Gerster^ uses 
an ingenious umhrella cannula. 

Laryngotomy. — Larj-ngotomy is essentially utilized for exposure of 
the interior of the air passages. The larjTix may be opened by 
partml or complete section of the thyroid cartilage, or the exposure 
may include the parts from the hyoid bone to the cricoid cartilage, 
or the latter may also be divided — total larjmgotomy. 



OPERATIONS ON THE AIR PASSAGES 



1753 



The entrance of blood and secretions into the trachea may be obvi- 
ated by placing the patient in Rose's position (p. 774) ; by the intro- 
duction of a tampo-n cannula, or by employing local anesthesia, in 
which ewnt the patient expels collections of fluid through the mouth. 
Total laryngotomy (laryngofissure) is a simple operation. The 
incisio)) is made in the median line, extending from the hyoid bone to 
the cricoid cartilage or a little lower. The sternal muscles are drawn 

aside, exposing the edge of 
the larynx. After the conoid 
ligament and the cricoid 
ring are divided, the thyroid 
cartilage is opened directly 
in the median line in order 
to avoid injury to the inser- 
tions of the vocal cords. A 
stout knife, scissors, or the 
Gigli saw may be used for 
the purpose. The special 
precautions with regard to 
the section are taken up in 
connection with tracheotomy. 
The ajter treatment is 
aim«d at preservation of the 
phonetic and respiratory 
functions of the larynx 
which of course is possiWe 
only in -accord with the ex- 
tent of the intralaryngeal 
operation. The outcome in 
this connection depends very 
much upon the care and ac- 
curacy with which the sec- 
tioned parts are apposed by 
suture. However, complete closure of the wound should not prejudice 
the intent of the intralaryngeal technic, nor should tamponade of the 
larjTix be omitted in cases in which this is indicated, especially for the 
arrest of bleeding. When the operation involves the danger of 
secondary stenosis, it is customary to suture the larynx over a cannula, 
which is frequently changed. Gluck*' has covered the raw surfaces of 
the interior of the larynx with skin flaps, and v. Bruns uses Thiersch 




Fig. 832. — Trendelenburg Tracheal 
Tampon Cannula. 



1754 



SURGERY OF THE NECK 



grafts for the same purpose (see also De Santi/ Le jars'* and 
Hofmeister"). 

Laryngectomy. — Malignant disease is practically the only indication 
for total or partial laryngectomy. The greater accuracy in diagnosis 
achieved in recent years has increased the number of successful opera- 
tions. The technic of partial and complete laryngectomy does not 
differ to any material extent. The advisability of partial laryngec- 
tomy in malignant disease is doubtful. The method of Gluck" is 
largely practiced at this time. While the extent of the operation is 
great, it must be re- 
membered that this 
is not objectionable 
w h e n relief from 
malignant disease is 
the intent. 

The skin incisions 
are made as follows, 
one from the h^^oid 
bone to the jugulum 
and two transverse 
extending from the 
anterior border of 
one of the sterno- 
mastoid muscles to 
the other, the upper 
being level with the 
hyoid bone and the 
lower with the cri- 
coid cartilage. In 
this way two quad- 
rangular flaps are outlined which are dissected back to their lateral 
attachments, the superficial veins being tied as the dissection pro- 
ceeds. Most surgeons simply separate the musculature from the 
larynx. In the method Gluck^ follows the sternohyoid, the omo- 
hyoid, the sternothyroid and the thj-rohj-oid muscles are resected, on 
the ground that they are no longer of use and their removal much 
increases the accessibility of the larynx, a view with which the writer 
is inclined to agree. Before doing this, the fascia must be divided to 
the full extent of the superficial incisions. Next, the isthmus of the 
thyroid gland is ligated, sectioned, and turned aside, or, if feasible, it 




Fig. 833. — Laryngofissure. 



OPERATIONS ON THE AIR PASSAGES 



1755 



is separated from the trachea and pulled downward. Either of these 
steps must be patiently carried out. The larynx is now drawn to one 
side, making the fibers of the constrictor of the piiarynx tense; the 
superior cornu of the larynx is separated from its musxjular attach- 
ment and the same steps are repeated on the opposite side. The follow- 
ing three arteries are now tied: The anterior division of the inferior 
thyroid (inferior laryngeal), the cricothyroid and the anterior laryn- 



>£?■'■■ 



Cavify of pharynx 
edge ofrnucDus ii: 



Artjt&enoid (^•■'.L: 




Entrance to !at u k 



Epiglottis 



Fig. 834. — Complete Laryngectomy. 



geal (branch of the superior thyroid) ; the laryngeal arteries must be 
tied before the air passage is opened ; the cricothyroid is unimportant 
and may be tied at any time. The superior laryngeal nerve has no 
longer any function and may be disregarded. 

The larj-nx is now separated from the hj^oid bone by dividing the 
thyrohyoid ligament close to the hyoid bone, the mucosa is cut just 
above the epiglottis, and the thyrohyoid membrane is sectioned laterally 
to the cornua of the thjToid cartilage. The larynx is delivered beyond 



1756 SURGERY OF THE NECK 

the niveau of the wound and is dissected from the pharynx and the 
esophagus. The patient is still breathing through the larynx, which is 
not yet invaded, and the narcosis is maintained through this avenue. 
Finally, a stroke of the knife sections the trachea at the lower edge of 
the cricoid cartilage and the extirpation is completed. Or, which is 
better, the defect in the anterior wall of the pharynx is closed with the 
larynx protruding from the wound. This is easily accomplished with 
a continuous chromic gut Lembert suture in two layers. The patient 
still breathes through the larynx by means of an ordinary rubber tube. 
Now the trachea is sectioned as stated, its stump fastened into the lower 
edge of the wound and the flaps closed by suture. Drains are intro- 
duced through the lower lateral angles of the wound. The after 
treatment is similar to that used in connection with tracheotomy. 

The whispered voice is remarkably serviceable ; however, a certain 
number of patients find solace in the emploj'ment of an artificial 
larynx. Of these, that of Oluck^ is perhaps the most useful. The 
space available here is not sufficient to permit of a satisfactory discus- 
sion of this a.spect of the situation (see bibliography). 



BIBLIOGRAPHY 

1. Franok. Miineh. med. Woch., 1906. 

2. Thost. Quoted by v. Bruns : Handb. d. pi-akt. Chir. ii, Stuttgart, 1913. 

3. St. Germain. Quoted by v. Brans : Handb. d. prakt. Chir. ii, Stuttgart, 

1913. 

4. Trendelenburg. Gerhardt's Handb. d. kinderkrank., etc., with com. lit. 

5. Gerster. Bryant's Op. Surer, i, N. Y. and London, 1905. 

6. Gluok. Handb. d. spec. Chir. des Ohres, etc., iv, Wiirzburg, 1913. 

7. De Santi. Brit. Med. Jr., 1895. 

8. Le.jars. Traite de chir. d' urgence, Paris, 1899. 

9. HOFMEISTER. Verb. d. Deutsch. Gesell. f. Chir., 1908. 



CHAPTER XI 
SURGERY OF THE THYROID GLAND 

Goiter. — By far the most frequent disease of the thyroid body is 
goiter. This may be endemic, epidemic, or sporadic. Strange to say, 
it shows a tendency toward geographical distribution. Where goiter 
is, endemic cretinism is present. 

Goiter is rarely congenital, except in the so-called goiter districts. 
It occurs most frequently in the female sex. This is ascribed to men- 
struation and pregnancy, special occupations, and the fact that women 
drink more water than do men. V. Eiselsberg^ regards the following 
factors as predisposing to goiter; heredity and the physiological 
swelling of the gland occurring during menstruation, pregnancy, and 
puberty. It is probable that the character of the drinking water has 
a causative influence. Perhaps the most extensive investigation with 
regard to the cause of goiter has been made by Bircher, jr.,^ whose 
studies of the influence of drinking water seem to have established its 
etiological connection. 

The term goiter (struma) indicates an enlargement of the thy- 
roid GLAND irrespective of its character or whether the entire gland or 
only a portion is affected. 

According to v. Eiselsberg,^ benign gaiters may be classified as 
follows : 

I. The diffuse forms. 

A. Parenchymatous. 

1. Adenoid with increase of follicles. 

2. Colloid with increase of follicular content. 

B. Fibrous (very rare) (myxedema?). 

C. Vascular — associated with active enlargement of blood 

vessels (aneurismal dilatation) or with passive enlarge- 
ment of the veins. 

II. The circumscribed forms. 

A. Glandular adenoid (local hypertrophy of the thyroid 
glandular tissue). 

. 1757 



1758 



SURGEKY OF THE NECK 



B, Colloid with varying metamorphoses; the formation of 

false and genuine cysts, calcification, ossification, 
fibrous and hyalin changes of the stroma. 

C, Vascular. 

D, Adenomata. 

1. Fetal adenoma. 

2. Tubular adenoma. 

3. Papillary cystadenoma. 

The parathyroids also undergo changes, the most important of which 
are chronic fibrous parathyroiditis, tuberculosis, cystic and tumorlike 
changes (Gutknecht,^ Kloeppel,"* Landois,'^ Halsted^). 

Of the local disturbances caused by goiter, 
pressure on contiguous structures is the most 
important. This includes compression of the 
trachea, esophagus, the vessels and the nerves. 

Pressure on the trachea is evinced by 
dyspnea and gives rise to displacement, 
stenosis, or changes in the tracheal wall. A 
fatal outcome in this connection is not uncom- 
mon. The esophagus is rarely sufficiently 
compressed to cause difficulty in deglutition. 
The vessels are uniformly dilated. Interfer- 
ence with the recurrent laryngeal nerve causes 
modification in the voice. 

The symptoms of goiter are dependent upon 
the rapidity with which the goiter develops. 
On the other hand, these are not propor- 
tionate to the size of the goiter ; a small 
retropharyngeal nodule, or one located in 

the thoracic aperture, may give rise to serious disturbances, while 
a pendulous goiter may hang well down on the thorax without 
interference with function. The first symptom the patient notices is 
that the collar is no longer large enough. The dominant symptom is 
dyspnea, especially upon exertion. While this usually becomes gradu- 
ally more and more marked, if the goiter enlarges slowl}^ the patient 
may continue to work with but little disturbance in breathing. In a 
certain number of cases pressure of a comparatively small goiter upon 
the laryngeal nerves gives rise to spasm and consequent grave inter- 
ference with respiration (goiter asthma). Retrosternal goiters are 
especially likely to provoke respiratory difficulties. Circulatory dis- 




FlG. 



835. — Scabbard 
Trachea. 



SURGERY OK TllK THYROID GLAND 



1759 



titrhaiiccs are of two kinds, those due to tracheal stenosis and intcr- 
ferenee with the pulmonary circulation, and the thyrogenous, the out- 
come of the toxic efTect upon cardiac innervation. No doubt direct 
in-itation of the vagus and sympathetic nerves in the neck is also a 
factor in tachycardia. Cyanosis of the face alternating with pallor 
are the first symptoms iu this counectiou; later, vertigo and syncope 




Fig. 836. — Colloid Goiter, Showing Dilated Veins. 



develop and, in a certain number of cases, the heart suddenly dilates 
and a fatal outcome ensues. The effect of pressure on the recurrent 
laryngeals is shown by hoarseness, spasm and cough. Prolonged pres- 
sure on both nerves results in apJionia and may threaten life from 
paralysis of the muscles of the larj'nx. Involvement of the trunk of 
the vagus is not common ; it is characterized by slowing of respiration. 



1760 SURGERY OF THE NECK 

Pressure on the sympathetic is attended with s^-mptoms of irritation 
and paralysis. The latter consist in contraction of the pupil, narrow- 
ing of the slit of the eyelids, and redness of the ear. Irritation causes 
dilatation of the pupil. 

Abnormal Position of Goiter — Accessory Goiter. — Congenital 
abnormalities of goiter are variouslj- designated. The term diving 
goiter (goitre plongeant of the French) is applied to a freely movable 
goiter which moves in and out of the thorax during respiration. 
Wander gaiter makes wide excursions, together with the larynx. It 
may become incarcerated in the thoracic aperture and give rise to 
severe dyspnea. Thyroptosis is a term applied to a goiter in which 
the entire isthmus and lower poles of the gland are prolapsed into the 
thorax. A goiter which encircles the trachea and esophagus is called 
a ring gaiter, and to those prolonged upward on either side, the term 
tubular goiter is applied. 

Accessory gaiters are divided into false and true. The former are 
connected with the thyroid gland, the latter are not. The false form 
is easily diagnosticated, while the true, because of its atypical location, 
often escapes recognition. Madelung^ offers the following anatomical 
classification in this connection : 

Glandulae thyroid, access, inferiores arising from the isthmus and 
extending behind the sternum, and those connected with a lateral lobe 
and extending into the retroclavicular space (Adjutolo^). 

Glandulae thyroid, access, posteriores develop from the lateral lohes 
and extend between the esophagus and the vertebral column. These 
interfere with deglutition (Kronlein^). 

Endotracheal accessory goiters are rare. They are due to errors in 
the embryonic anlage (v. Bruns^''). See Surgery of the Larj-nx, 
p. 1722. 

Glandulae thyroid, aacess. sxcp. are represented by the pyramidal 
process type of false accessory goiter which is very common. It often 
extends to the hyoid bone (see Tracheotomy, p. 1747). 

Lingual goiter is of especial importance. It appears at the site of 
the foramen cecum (Chamisso de Boncourt^O in the form of a broadly 
attached tumor, rarely larger than a hen's egg, usually the size of a 
cherry (see Surgery of the Tongue, Part IX). 

The dia/jnosis of struma may usually be made by examination, irre- 
spective of the his1?ory. The examination consists in the employment 
of inspection, palpation, the laryngoscope, and the Rontgenogram. 

Inspection gives information regarding the patient's general con- 



SURGERY OF THE THYROID GLAND 



1761 



dition, such as coiif^estioii of the face, dyspnea, sympathetic sym])toms 
(the eye) and also establishes the size, location, and general form of 
the goiter, and the condition of the superimposed skin. Very often 
the carotid pulse is visible at the outer border of the sternomastoid 
muscle. The fact that the tumor moves with the act of degluti- 




FiG. 837. — Enormous Cystic Goiter. 

TiON IS OF GREAT DIAGNOSTIC SIGNIFICANCE. This symptom is absent in 
cases of carcinomatous infiltration of the gland. 

Palpation reveals the location of the thyroid incisure and of the 
carotid. Large goiters always push the latter to the outer posterior 
edge of the sternomastoid muscle. The consistence of the goiter must 
be carefull}^ determined, i. e., whether soft, hard, nodular, or cystic; 
determination of its motility is equally important. 



1762 SURGERY OF THE XECK 

Auscultation often reveals the presence of a bruit. 

It Ls also important to determine the relationship that the tumor 
bears to the trachea and larynx. The patient should be examined with 
the mirror, not, as a rule, with the direct laryngoscope; the latter is 
likely to be very trying. The Ednigeiiogram gives ample informa- 
tinn in regard to the degree of tracheal stenosis. Aspiration is of 
doubtful utility. The therapeutic test, i. e., the administration of 
iodin, is helpful in connection with lingual goiter. The diagnosis 
slwuld a-i/ii at dftermining the character of goiter. In this, all the 
characteristics of the struma weighed against the classification given 
above must be taken into account. 

The Treatment of Goiter. — While the therapy of advanced 
struma attended with subjective symptoms belongs to the field of sur- 
gery, there is no doubt that the majority of those of moderate degree 
are susceptible to great improvement by internal medication. 

The prophylactic treatment consists in the avoidance of so-called 
''goiter districts" or, if this is impracticable, onh* special drinking 
water .should be partaken of. Under no circumstances must the local 
water be used for drinking purposes. Filtration does not prevent the 
deleterious effect of the water. 

The Medicinal Treatment. — The administration of iodin was intro- 
duced by Coindet (1820). Its efficacy is attested by Kocher/- who 
states that "90 per cent of all goiters are so much improved by the 
administration of iodin that operative measures are unnecessary. ' ' A 
10-20 per cent solution of potassium iodid or a 0.1, 1.0, 10.0 per cent 
iodin ointment is applied to the goiter in conjunction with the admin- 
istration of 0.1-0.2 gm. of potas.sium or sodium iodid pro die. 
Saturation of the body with iodin is attended with so-called iodin 
marasm us, the symptom complex of which resembles Basedow "s disease. 
This is best combated with acid sodium phosphate. The treatment is 
especially efficacious in the hyperplastic and parench\Tnatous forms of 
struma ; in the fibrous and calcareous forms it is of no avail 
(Kocher^2) 

Organotherapjj owes its efficacy to the iodin content of the gland. 
It has been much employed in ca-ses of follicular .struma (Baumann^^). 
V. EiseLsberg^ does not regard the method as possessing any advantage 
over the use of iodin. Its objectionable features lie in the tachycardia 
and vertigo it causes : these may result in a fatal outcome. 

The injectieyn of iodin preparations has also been abandoned (v. 
Eiselsberg.^ See also McCarrison" and Crotti^'^). 



SURGERY OF THE THYROID GLAND 



1763 



Operative Tcchnic. — In cases in which the goiter causes menacing 
symptoms or when the medicinal treatment is not efficacious, operative 
measures of relief may be employed. These may be divided into 
(1) partial extirpation, in which a greater or lesser portion of the 
gland is removed ; (2) emtcZeaf/o?i of isolated goiter nodules ; and (3) 
resection of a portion of the goiter, which is often a combination of 
extirpation and enucleation. 

With regard to anesthesia, one may say that experienced goiter 




Fig. 838. — Extirpation op Goiter (Koeher). 

1. Skin flap with fascia and platysma. 2. Sternomastoid muscle. 3. Sterno- 
hyoid muscle. 4. Goiter. 5. Sternothyroid muscle. 



operators use local anesthesia, but that carefully administered ether 
narcosis does not increase the dangers of the operation. 

The incision of approach may vary; however, as a rule, the trans- 
verse section of Koeher^- (krag-enschnit) is universally employed, 
except for removal of small nodules when an atypical incision may be 
used. The transverse incision has a slight downward convexity from 
one sternomastoid muscle to the other and is centered over the dome of 
the goiter (Figure 838). The median veins of the neck are tied. 



176-i SURGERY OF THE NECK 

The muscles are divided as shown, including the omohj'oids; the 
muscles are subsequently sutured. The goiter is usually spontaneously 
luxated be^'ond the niveau of the wound. The vascular middle fascia 
is divided, exposing the capsule of the struma. 

In partial extirpation the goiter sound or the finger delivers the 
upper pole beyond the skin (this must not kink the trachea) and the 
superior thyroid vessels are tied and cut ; the lower pole is next 
delivered and the inferior thyroid vessels are ligated and divided 
between the ligatures. Care is taken not to traumatize the parathy- 
raid bodies. The recurrent larsTigeal nerves are best avoided by leav- 
ing the posterior portion of the gland in situ. The greater part of 
both lobes, or one lobe in its entirety, may now be removed. Unilateral 
strumectomy is the method of choice (Kocher^-). The isthmus may 
be ligated or crushed with forceps and sutured. Bleeding must he 
carefully arrested. A drain (rubber tissue) is passed through the 
wound. Halsted^ closes the superficial wound with a subcuticular 
suture. 

Enucleatiwi is the outcome of a desire to avoid injury to the nerves, 
to be sure that enough gland is left in situ, and to avoid trauma to or 
removal of the parathyroid bodies. The technic of exposure is similar 
to that already described ; the nodule or nodules are located by pal- 
pation and the afferent vessels are encircled by transfixion sutures and 
tied. The parenchjTna is then incised and the doomed structures 
enucleated with the goiter sound or the fijiger. Oozing is controlled 
by packing and ultimately drained with gauze. The method is now 
restricted to the enucleatio7i of cysts (Kocher^-). 

The combination of extirpation with resection and extirpation with 
enucleation is a modification of v. Mikulicz's method introduced by 
himself. After the superior thjToid vessels are tied, a wedge-shaped 
portion of the gland on either side, extending down to the isthmus, is 
excised and the resultant wound is sutured. Its technic and its bear- 
ing on preservation of the parathjToid bodies has been carefully 
worked out by Pool and Falk^^. 

Recurrences after goiter operations are regarded in the sense of 
compensatory hypertrophies. Clinically, they may be di^-ided into 
those that do and those that do not cause disturbances (other than 
cosmetic effect). Of 600 goiter operations performed in v. Bruns" 
clinic, only twelve required secondary operation. The symptomatol- 
ogy' of recurrent struma is similar to that of the primary affection. 

The Dangers of Goiter Operations. — The operative fatalities of 



SURGERY OF THE THYROID GLAND 1765 

goiter operations in Reverdin's statistics, comprising 6103 cases, show 
a mortality' of 2.88 per cent; Kocher's mortality of recent years is 
0.2 per cent (Crotti''^). Of the complications, bleeding is the most 
serious; the danger of air embolism is much exaggerated. Of the 
nerves, division or injury of the recurrent laryngeal is a distressing 
occurrence. Infection is an exceedingly menacing complication. For- 
tunately it is rare and is obviated by care in the execution of asepsis. 

The special dangers of struma operations ma}' be separated into two 
groups, tetany and cachexia. 

Tetania parathyropriva is comparatively rare, as total extirpation of 
the thjToid gland is no longer practiced and thus the parathyroid 
bodies are spared. 

The disease is characterized by convulsive seizures — resembling 
tetanus — which attack the muscles of the extremities, the larj'nx and 
the diaphragm ; the last may prove fatal. Tetany may begin imme- 
diately after the patient emerges from narcosis or several days (up to 
ten) later. As a rule, a prodromal period is observ'able, a feeling of 
discomfort, stiffness and weakness of the general musculature — espe- 
cially in the muscles of the forearm and calf. The dia{)nosis may often, 
be based upon these symptoms, together with the demonstration of 
Chvostek's or Trousseau's signs. In the former, a sharp tap over the 
facial nerve in the parotid gland provokes spasm of the facial muscles 
on that side; the second consists of a cramp of an extremity when 
pressure is made on its main artery or nerve. 

In cases of moderate degree the disturbances are limited to tonic 
spasm of the upper extremities, especially the forearm; the elbow, the 
wrist and the basal phalanges are flexed, the other finger joints are 
extended ; the thumb is apposed to the palm, that is, the typical 
"obstetrical hand." 

In severe cases the backs of the hands are turned toward one another 
(in the manner seen in "siren malformation"), the lower extremities 
are contracted, the hips and knees are extended, the feet and toes are 
held in plantar flexion. Contraction of the muscles causes pain, the 
pulse is rapid, fever is absent; the sensorium remains clear (unfor- 
tunately). 

This picture is paroxysmal, the attacks varying from two to fifteen 
minutes in duration and extending over several days at a time. Death 
is the outcome of diaphragmatic fixation. A certain number of cases 
recover spontaneously, while not a few go on to chronic tetany. 
Tetania parathyroidopriva has followed partial strumectomy; this is 



1766 SURGERY OF THE NECK 

explained on the ground that the epithelial bodies vary widely as to 
location and may thus be inadvertently injured or removed, despite 
the employment of a technic designed to avoid them (see Nos. 14, 15 
and 16 of bibliography') . The affliction has followed ligature of the 
four th;v-roid arteries (v. Eiselsberg^). 

Spontaneous improvement of tetany has occurred in accord with 
demonstrable regeneration of thyroid tissue, which probably included 
growth of parathyroid substance. In this connection, v. Eiselsberg^ 
reports an instructive case. Of 1157 cases operated upon in eleven 
years in the clinic of this persistent worker, thirteen developed tetany 
of which three died, seven of the remaining ten gradually recovered, 
and three slowly improved after years of invalidism. One of these 
was ultimately benefited after two transplantations of thyroid bodies. 
The first attempt was not followed by much improvement ; the second 
time, a fresh parathyroid was transplanted from a suicide and was 
followed by marked lessening of the symptoms. 

Cases of moderate postoperative tetany, in which a slight Chvostek 
is present, seem to be benefited by the administration of calcium lactate 
(6-9 gms. p. d.). Halsted''' reports favorable results following the 
administration of parathyroidin deriA-ed from the sheep. In menacing 
cases, transplantation of parathyroid bodies comes under consideration 
(Pool-Falk^^). 

Cachexia thyroprivia develops slowly after strumectomy and may 
be secondary- to tetany. Myxedema operativuni chroniciim was first 
described by Reverdin.^' The dominant characteristics of the disease 
consist in lessening of mental capacity, intelligence and energy and in 
an edematous swelling of the skin. In young persons general bodily 
development is inhibited. 

Many patients remain normal for a long time (j'ears) after the 
operation and then the sj^mptoms stated above gradually develop. 
The changes in the skin make the diagnosis patent. The skin of the 
face is dr}', waxy and ''puffed" and the excretion of sweat and the 
secretion of sebum are arrested. The hair loses its luster and may 
fall. The lower lids sag, the play of expression is absent and the 
features convey the notion of apathy. The edema, which does not pit, 
slowly extends to the extremities and trunk. In the supraclavicular 
regions it protrudes in a form bearing some resemblance to lipoma. 
In not a few instances the mucosa of the mouth is affected, so that 
speech is thick and indistinct — a distressing accentuation of the 
idiotic picture. The blood shows domination of hemoglobin content 



SURGERY OF THE THYROID GLAND 



17G7 



and lessening of leukocytes. In children, the long bones cease to grow 
(v. Bruns^"), while the diameter of the epiphyses continues to increase. 
Sexual development is inhibited or remains stationary. The patient's 
resistance to cold is decreased. 

According to the collected statistics of v. Eiselsberg/ 70 per cent of 
the eases subjected to total strumectomy show acute or chronic myx- 




FiG. 839. — Cachexia Thyropriva (Myxedema). 



edema and tetany. Of 900 cases of partial strumectomy, only one (for 
malignant disease) showed cachexia (Kocher^^). Of 2000 cases 
operated upon by the Mayos," 2 developed cachexia. 

The observation that cachexia is prevented by leaving sufficient 
glandular structure in situ, and that when omission to make proper 
provision of this sort has been followed by cachexia this disappeared 
as the residual glandular tissue grew, led to the development of an 



1768 SURGERY OF THE NECK 

adequate therapy in this connection. In these cases, organotherapy, 
in the form of implantation, injection and administration of the 
thyroid tissue, has achieved a notable triumph. At present, the admin- 
istration of thyroid extract is universally practiced. 

Ligature of the Thyroid Arteries. — Ligature of the thyroid 
arteries (Wolfler^") is practiced for the relief of parenchymatous 
struma, especially when this form of goiter appears in young persons 
and grows rapidly. To accomplish the purpose, all of the four arteries 
must be tied at one sitting. Cachexia and tetanj^ has followed the 
measure. TTie method has a distinct field of usefulness 'in Basedow 's 
disease. 

Luxation of the Goiter. — Exothj^ropexia (Poncet et Jaboulay^^) 
consists in exposing the goiter as stated above and permitting it to 
prolapse through the wound. Gradual atrophy of the gland takes 
place. In cases -of goiter attended with great pressure, the procedure 
may save life. 

Tracheotomy in Connection with Goiter. — Tracheotomy- in con- 
nection with goiter is a palliative measure. The masked position of 
the trachea makes this an extremely difficult procedure (see also 
Berry,-- Hastings^^ and Verebely^*). 

Inflammations of the Normal Thyroid Gland and of Goiter. — The sim- 
ilarity of the inflammator}^ processes invading the thyroid bod}' and 
goiter justifies considering them together. Of the various forms of 
goiter, the follicular and cystic are most often affected. 

Thyroiditis is usually the result of direct injury with subsequent 
infection ; or it occurs in connection with -a general infection and is 
then of metastatic origin. Metastatic thyroiditis or strumitis develops 
in the course of typhoid, pyemia, puerperal fever, pneumonitis, scarla- 
tina, variola, diphtheria, and rheumatisin. Acute suppurative strum- 
itis has been •caused by infection with the bacterium communis eoli 
(Brunner^^). 

The symptoms are those common to all infectious inflammatory pro- 
cesses. Rapid swelling of the gland may provoke respiratory disturb- 
ances. The process results in resolution (rare), suppuration, and 
necrosis. Suppuration may perforate externally or into the trachea 
or esophagus ; erosion into the carotid artery has occurred. Necrosis 
is simply a severe form of inflammation. 

The treatment is similar to that of all inflammatory processes. 
Incision must he liberal and not too long delayed. V. Eiselsberg^ has 
observed fatal tetany in connection with severe, acute, purulent thy- 



SURGERY OF THE THYROID GLAND 1769 

roiditis. Autopsy indicated that the parathyroids had been destroyed. 
A residual fistula calls for partial thyroidectomy. A low grade of 
strumitis may simulate malignant disease. 

Specific Thyroiditis. — Tuberculous thyroiditis appears in two 
forms. The one form consists in miliurij nodules and is a part of 
general miliarj^ tuberculosis. The second, which is rare, appears in 
the form of tuherculaus nodules which give rise to pain and dyspnea. 
Involvement of the contiguous lymph nodes gives the process the 
appearance of malignant disease. As a rule, the microscopical findings 
clear up the diagnosis (Claremont^*). 

Actinomycosis of the thyroid gland is very rare. It has been re- 
sponsible for mj-xedema (Kohler^'). 

Lues of the thyroid gland occurs in the secondary stage of the dis- 
ease as a part of the lymphatic disturbances; it is transient in char- 
acter. In the tertiary stage, diffuse luetic thjToiditis may be respon- 
sible for myxedema (Kiittner^®). However, the gummatous form of 
the disease possesses the greatest surgical importance. Like tubercu- 
losis, it presents a picture very similar to that of malignant disease. 
The diagnosis would have to rest on the therapeutic test, together with 
the serological findings. 

Echinococcus of the thyroid gland presents itself with the clinical 
manifestations of a cystic goiter. A cystic goiter attended with 
"purring" and urticaria may suggest the diagnosis. This niay be 
verified by aspiration and the serum reaction (p. 1325). Enucleation 
of the process is the therapy of choice (Vitrac,^^ Ultzmann^°). 

Tumors of the Thyroid Gland. — Aside from adenomata (alluded to 
above) benign tumors of the thyroid gland are very rare. This con- 
sideration has some diagnostic significance -u-ith regard to the specific 
infections and malignant disease. Carcinomata and sarcomata occur 
most often in goitrous thyroid glands. In 7,700 autopsies, thyroid 
carcinoma was found eleven times and sarcoma five (Chiari^^). 

Sarcoma of the thyroid appears in the form of a rapidly growing 
tumor beginning in a lobe and soon involving the entire organ. The 
growth soon perforates the capsule and invades the various structures 
of the neck. Operative removal holds out the possibility of relief only 
when performed early in the disease. Carcinoma makes its initial 
appearance in the form of a circumscribed infiltrate or nodule. As a 
rule, the entire gland is soon invaded, although adenocarcinoma and 
scirrhus may remain restricted to a single lobe. The capsule is per- 
forated earlv in the disease ; this is soon followed bv difficulties in 



1770 



SURGERY OF THE NECK 



swallowmg and deglutition. Metastases are very common. Of the 
various forms of carcinoma, the alveolar is most frequently found. 

At first, the diagnosis is difficult; later, it is unmistakable. When, in an 
elderly person, a goiter which has persisted for a long time suddenly increases 
in size, and at the same time the gland becomes hard, the lymph nodes enlarge 
and lancinating pain appears, together with dyspnea and dysphagia, the 
diagnosis of cancer may he made with reasonable certainty. 




Fig. 840. — Cretinism: (Eleven year old child). 

Operative removal is indicated only when the capsule is not per- 
forated. An effort should be made to spare the parathyroid bodies 
(see Nos, 14, 15 of the bibliography). 

Excision of a specimen for microscopical examination in suspected 
malignant disease is justifiable only if immediate operative removal is 
contemplated. The opening thus made in the capsule favors rapid 
extension of the disease to the neighboring tissues (v. Eiselsberg^). 

Cretinism. — Goiter is an early sj-mptom of the degenerating pro- 
cesses, the last grade of which is cretinism. Bircher^ holds that the 



SURGERY OF THE THYROID GLAND 1771 

two processes simply occur together. Studies of the affection in the 
Jewish race seem to show that a cretinic generation follows one of 
goiterism (Flinker^-). The causative influence of the drinking water 
of certain districts has been demonstrated by v. Wagner. ^-^ Cretinism 
is characterized by (1) disturbances of growth, specific changes in 
the skin, and incomplete development of the genitals; (2) idiocy; 
(3) goitrous degeneration, or absence of the thyroid gland. 

The arrest of growth and the changes in the skin have already been 
discussed. The abnormalities of the genitals in cretinism are espe- 
cially characteristic. The penis, scrotum, labia, and uterus remain in 
a prepubertal condition. However, the capacity of reproduction may 
appear later in life, so that a cretinic woman may bear children. 
Idiocy is regarded as due to underdevelopment of the brain, (v. 
Wagner^^) ; hearing is the most seriously impaired of the special 
senses (Kocher^-). The thyroid gland is always abnormal; the para- 
thyroids seem to be unaffected (Chiari^^). The administration of thy- 
roid tissue is followed by improvement. This, in some instances, is 
startling (v. Eiselsberg^). 

Spontaneous myxedema in the adult occurs when the function of the 
thjToid gland is lessened. It is attended with changes in the skin and 
in the psychic attitude of the patient. It is too late for disturbances 
in development to appear. The changes in the skin are similar to 
those already discussed. The psychic disturbances consist in apathy 
and stupidity. Charcot compares the mental condition to that of a 
hibernating animal. Speech is impaired "as though the speech mech- 
anism were frozen" (v. Ei.selsberg^). The thyroid gland is either 
goitr&us or decreased in size; the latter is the rule. The notion that 
hypothyroidism is responsible for the clinical picture of myxedema is 
supported by the an-alogy it bears to cretinism. The disease is insid- 
ious in its onset and may escape recognition in its early stages. The 
administration -of thyroid preparations, especially of Baumann's^^ 
thyroiodin, is of signal service. 

Exophthalmic Goiter (Basedow's, or Graves', Disease). — The dom- 
inayit symptoms of Basedow's disease consist in struma, exophthalmos, 
tachycardia and tremor, to which may be added a number of nervous 
disturbances. As a rule, the thyroid gland is enlarged, tender, hard, 
uniformly granular (like the mamman," gland of a woman during 
lactation — Kocher), and very vascular. A bruit may very often be 
heard over the thyroid arteries — before the gland enlarges ; however, 



1772 



SUKGERY OF THE NECK 



struma usually is not marked. Section shows an almost complete 
absence of colloid. 

The histological findings may be stated as follows: (1) Epithelial 
proliferation with the production of larger and smaller hollow spaces 
and tubules, canals, and papillary excrescences. (2) The epithelial 
cells vary in size and form, being cylindrical in the tubules, and show 
a tendency to desquamate. 
The epithelial garlands 
are irregularly formed. 
(3) Most of the sectors of 
the gland are sparingly 
furnished with typical 
colloid; the spaces are 
filled by cysts and tubules, 
which contain a pale, 
granular, rarely homogen- 
ous material. The striped 
and unstriped muscular 
fibers are degenerated. 

Exophthalmos is at- 
tended with additional 
eye symptoms as follows: 
(1) V. Graefe's sign — 
the upper eyelid does not 
follow the eyeball in its 
vertical excursions; (2) 
Stillwagon's symptom — 
abnormal separation of 
the eyelids. The upper 
eyelid is permanently re- 
tracted. Mohius' symp- 
tom — insufficient c o n - 
vergence of the eyeball 
without diplopia. 

Tachycardia is an early sjonptom ; the pulse often reaches 120-140 
per minute. A coexisting myxocarditis usually results fatally. 

The Uood picture is characteristic, leukopenia with diminution of 
the neutrophiles and increase in Ijnnphocytes. The coagulation period 
of the blood is increased. 



■■HHHBB|Hfl 


■■■HH|' 


^^^^^^^^^H|U0R5 


^^^^^^^^^^^^Isw 










^^^^^^^^^^^^^^^' 


" ^y^«*6*it^~ ^ 


^^^^^^^^^K 


*^A \ 


^^^^^^^^^^^^r 


jS 


^^^^^^^^^^K 


^'T^^ 


^^^^» ^' 


wSk. 


^^HLr* 


f^ 


^^^^^^^^^Bmb* 


^ ^M ^ 


^^^^^^^^^K^^^K^^^^ 


i^p^ 


^H^P^^Mrtk, 


J^m 


^^^^^^^K. WfJ/K/fS^^ A ^^^M 


■H 


^^^^^^^^» '^ ' MJij|ye5»ayfA^a||B 


^^v'^^k. 


^^^^^Kt ^ -..^■HHgHI 


H^* '^t 


^H^ " iHP 




■Mi 


!► 


1 


1 







Fig. 841. — Exophthalmic Goiter (Falk). 



SURGEKY OF THE THYROID GLAND 1773 

The tremor is like that of alcoholism, but, unlike this, is not limited 
to the extremities. 

The skin shows evidence of vasomotosecretory disturbances — in- 
creased diaphoresis, abnormal pigmentation, edema and insular hyper- 
emia. Attacks of diarrhea, emaciation, muscular weakness, and 
hysteria are common occurrences. 

The administration of thyroid substance always increases or pro- 
vokes tachj'cardia. 

The cause of Graves' disease was for a long time believed to lie in 
disorders of the nervous system, especially the sympatheticus and the 
medulla. It is certain that this notion is not susceptible of scientific 
proof. The theory of the day is that of Moebius, who ascribes the 
disease to an overproduction of, or an abnormal change in, the 
CHARACTER OF THE THYROID SECRETION, i, 6., hj'perthj^roidism, or per- 
haps dysthyroidization. The fact that the sjTnptoms are so exactly 
contrar}^ to those produced b}^ hypothj^roidism makes the theory sound 
rational. 

The disease appears most frequently in women at or near puberty. 
As a rule, it runs a chronic course. Spontaneous healing is rare, 
although remissions are frequent ; palliative treatment is illusionary. 

The diagnosis in defined cases is easy. Early in the disease, and in 
mild cases, the affections which provoke one or more of the symptoms 
must be excluded. 

The treatment of Basedow's disease by medicinal agents, including 
Moebius' serum, need not be discussed here. The Rontgen ray treat- 
ment is perhaps of value. Its emploj^ment makes subsequent operative 
treatment more difficult. Wliile not every person presenting symp- 
toms indicative of hyperthyroidism need be subjected to an operative 
procedure, there is no doubt that no other method of treatment 
achieves the same results. The various operative methods, including 
ligature of the arteries, show an average mortality of about two per 
cent. In this connection the statistics of the Mayos are of interest. 
These show 70 per cent cured and the rest improved. At this writing 
partial thyroidectomy is the operation of choice. The ligature of the 
arteries should be restricted to casas in which the more extensive 
operations are manifestly dangerous. This viewpoint seems to be that 
of Kocher, the Mayos, and v. Eiselsberg. Kocher and v. Eiselsberg 
use local anesthesia ; the Mayos and Crile employ general narcosis. 
The latter is particularly careful not to expose his patient unneces- 
sarily to the "horrors of operation," a conception one cannot help but 



1774 SURGERY OF THE NECK 

give serious consideration, especially when the nervous symptoms coin- 
cident to the disease are taken into account. On the other hand, local 
anesthesia, in the hands of the skilled technician, applied to patients 
to whom the necessary manipulations are not a ''horror" possesses 
many advantag-es. The persistence of the thymus does not constitute 
a contramdication to the operation, but entails special care in its 
execution. Exothyropexia is no longer practiced for the relief of 
hyperthyroidism, nor is resection of the sympathetic in the neck re- 
garded as serving a useful purpose. Thynwidectomy for the relief of 
the sjTnptoms of hyperthyroidism is not yet an established procedure. 
A recapitulation of the clinical manifestations attendant upon dis- 
eases of the thyroid gland and the parathyroid bodies may be arranged 
as follows: 

A. Hypothyroidism. 

1. Spontaneous hypothyroidism. 

a. Endemic, congenital and acquired cretinism. 

b. Sporadic cretinism, infantile myxedema. 

c. Spontaneous myxedema of the adult. 

2. Traumatic hypothyroidism (cachexia thyropriva). 

B. Hypoparathyroidism,. 

1. Spontaneous tetany (in children). 

2. Postoperative tetania parathyropriva. Transition from 

spontaneous into traumatic tetany occurs in suppura- 
tive or other destructive lesions of the parathyroid 
bodies. 

C. Hyperthyroidism (morbus Basedowii). 

Z>. Hyperparathyroidism, not yet understood but responsible for 
certain nervous disturbances, such as myasthenia gravis and 
paralysis agitans. 

BIBLIOGRAPHY 

1. V. EiSELSBERG. Handb. d. prakt. Cbir. ii, Stuttgart, 1913. 

2. BiRCHER, JR. Deutseh. med. Woeh., 1910; Deutseh. Zeitschr. f. Chir., 

1911 ; Munch, med. Woeh., 1912, No. 2. 

3. GuTKNECHT. Virchow's Arch. xcix. 

4. Kloppel. Zies'ler's Beitr., 1910, xxi. 

5. Landois. Virchow's Arch., 1911. 

6. Halsted. Johns Hopkins Hosp. Report, 1896. 

7. Madelung. No. 5. 

8. Adjutolo. Delia, strume tiroidu access., Bologna, 1890. 

9. Kronlein. See No. 1. 



SURGERY OF THE THYROID GLAND 1775 

10. V. Brun8. Bei'tr, z. klin. Chir. xli. 

11. Chamisso dk Boncourt. v. Bruns' Beitr. xix. 

12. KocHER. Therapie des kopfes. Deutsch. Clinic, 1904. 

13. Baumann. Zeitsclir. f. physiol. Chem., 1890. 

14. McCarkison. The Thyroid Gland, London, 1917. 

15. Crotti. Thyroid and Thymus, N. Y., 1918. 

16. Pool and Falk. Anus, of Surg., 1916. 

17. Revehuin. Cong, franc, de Chir., 1898. 

18. KocHER. Verh. d. Deutsch. Gesell. f. Chir., 1883. 

19. Mayo Brothers. Personal communication, April, 1919. 

20. Wolfler. Wien. med. Woch., 1880. 

21. PoNCET ET Jaboulay. Gaz. des hopit. Ixviii, 1894. 

22. Berry. Med. Presse, 1906. 

23. Hastings. Lancet, 1910. 

24. Verebely. Wien. med. Woch., 1910. 

25. Brunner. Korrest f. Schweizer-Arzt., 1892. 

26. Clairmont. Wien. klin. Woch., 1902. 

27. KOHLER. Berlin, klin. Woch., 1894. 

28. KiJTTNER. V. Biiins' Beitr. z. klin. Chir. xxii. 

29. ViTRAC. Rev. de chir., 1897. 

30. Ultzmann. Wien. klin. Woch., 1909. 

31. Chiari. Quoted by No. 1. 

32. FlixNKer. See Nos. 14, 15. 

33. V. Wagner. See No. 12. 

The literature of exophthalmic goiter is too extensive to be included here. 

The reader is referred to Nos. 14, 15 of the bibliography and to Kocher's 

"Le prix Nobel." 



PART xni 

THE SURGERY OF THE THYMUS GLAND 



CHAPTER I 

DISEASES OF THE THYMUS GLAND 

Thymus Hyperplasia. — Qualitative changes in the parenchyma of its 
glandular structure is the basis of hyperplasia of the thymus. Usually, 
the medullary portion is increased and the capsule atrophied. The 
hassall corpuscles are diminished in number, enlarged and present 
regressive changes. Simultaneous hyperplasia of medulla and capsule 
is rare. 

On the one hand, thymus hyperplasia is expressed in the form of a 
congenital insufficiency ; on the other, it is attended with evidence of 
either dysthymization or hyperthymization. The process is always a 
part of more or less extensive changes in the entire lymphatic appa- 
ratus. The occurrence of sudden death in cases of demonstrable 
thymus hyperplasia is ascribed to an abnormal constitutional 
lymphaticochlorotic dyscrasia which affects the intracardial centers 
and results in arrest of cardiac function. This ma}' happen after even 
slight external irritation. While this explanation accounts for a cer- 
tain number of "narcosis deaths," it has also been shown that in not 
a few instances, the fatal outcome in children is due to suffocation and 
that dysthjTnization only plays a secondary part (Hammar^). lOose^ 
seems to have shown that the irritation of surgical attack upon the 
gland is followed by regeneration of healthy thjonus tissue. This 
accounts for the local relief and the beneficial constitutional effects 
which follow the restriction of the abnormal internal secretion of the 
organ. Complete restitution to the normal is not to be expected, on the 
ground that the underlying causative factor is not removed by the 
surgical mea.sures (see also Crotti^). 

In the causation of thymus hyperplasia and aplasia, heredity plays 
an important part. The influence of chronic alcoholism in the par- 
entage is undoubtedly the most important factor in this connection. 
The causative relationship of lues is also clearly established. It is 
probable that the influence of consanguinity has been overestimated. 
Disturbances of respiration constitute the chief indication for 
operation. 

1779 



1780 THE SURGERY OF THE THYMUS GLAND 



Thymic stenosis develops in the first year of life. The infant 
breathes noisily ; this is especially marked during excitement and per- 
sists night and day. Respiration is attended with a snoring, bleating 
or gurgling sound. The epiclavicular depressions are exaggerated 
during inspiration. Infants with thymic stridor are always affected 
with hyperplasia of the th^Tnus. Persistent dyspnea is often exacer- 




FiG. 842. — EoxTGEXOGRAM OF AN EXL.VRGED THYiius (Harlem Hospital case). 

bated and occasionally one of the attacks proves fatal. The attacks 
are precipitated by any posture or mechanical influence which pro- 
duces venous stasis in the neck. 

The diagnosis is based on the 'physical and biological findings. Per- 
cussion reveals the dimensions of the gland, which throws a clearly 
defined shadow upon the Rontgenographic negative. The hlood 
shows a marked leukocytosis (80 per cent). Thymic stenosis should 
be recognized by the respiratory embarra.ssment. Esophageal stenosis 



DISEASES OF THE THYMUS GLAND 1781 

is not as common as the tracheal. Difficulty in deglutition is an indi- 
cation I'or operation, especially if tracheal stenosis is also present — 
which is usually the case. Dyspnea without a lesion of the nose or 
throat should lead to the suspicion of thymic stenosis. The vagus u 
often included in the pressure zone of a hyperplastic thymus gland, 
but is probably not directly responsible for a fatal outcome. Slowing 
of the pulse rale indicates vagus irritation. Pressure on the blood 
vessels is a distinct indication for operation. 

Narcosis death in children may often be ascribed to pressure caused 
by thymus hyperplasia. The mechanical causation does not, however, 
explain the fatal outcome in the adult. This would seem to be prop- 
erly ascribed to cardiac shock. In these cases, hyperplasia of the 
t^iymus and disturbances in the chromatic system (hypoplasia) are 
regarded as the causative factor. It has been shown that the thymus 
gland furnishes a horm-one which is antagonistic to the action of 
adrenalin upon the vagus (Wiescl,* Marfan'^). 

Circulatory and Inflammatory Disturbances of the Thymus Gland. — 
A normal thymus gland may become secondarily enlarged and cause 
death by pressure. Congestions, hemorrhages, and necroses have been 
observed in connection with inflammatory processes in the neck, espe- 
cially those occurring in the course of infectious diseases (diphtheria). 
Diffuse hematomata occur as a part of melena neonatorum. Obstet- 
ricians call attention to changes in the thymus resulting from trauma 
during delivery of the infant. The lesion is one of multiple hemor- 
rhagic areas of infiltration. No doubt the condition is often responsible 
for asphyxia- in the newly born. Suspicion of pressure from this cause 
justifies decompressive incision of the gland in the jugulum. 

Metastatic abscesses occur in the exanthema of children. Isolated 
gumma and solitary tubercle are rare. Leukemic and granulomatous 
infiltrations develop in connection with similar processes in the medi- 
astinal lymph nodes. 

Tumors of the Thymus Gland. — New growths of the thymus present 
themselves in the guise of slowly growing tumors of the mediastinum. 
The diagnosis is not made until the affection is sufficiently advanced to 
cause pressure, and then it must take a number of conditions into 
account. The Eontgenogram is of particular diagnostic value. 

Of the benign tumors, lipomata, dermoids, and ciliated epithelial 
cysts are the most common. 

Sarcoma is more often found than is carcinoma. The former has 
been responsible for the clinical picture of myasthenia gravis pseudo- 



1782 THE SURGERY OF THE THYMUS GLAND 

parabjtica ('Hammar^). Carcinoma is usually of the medullary form. 

Thymus Gland and Graves' Disease. — Although isolated diseases of 
the thymus g-land may produce symptoms of constitutional poisoning 
resembling Graves' disease, clinical experience does not give us the 
right to characterize the process as "thymogenous" Graves' disease. 
The part that the thymus gland plays in the clinical picture of Graves' 
disease has been recently established. The sprecial sj'mptoms for which 
it is responsible are blood changes, i. e., lymphocytosis and toxemia 
(Klose-). 

The pathological changes in Graves' disease are not influenced by 
excision of the thyroid gland. If these are to te remedied the opera- 
tive attack must include resection of the thymus with that made upon 
the thyroid gland. However, this indication is only relative, as expe- 
rience teaches that the symptom complex of Graves' disease disappears 
entirely as the outcome of the thyroid operation, i. e., return to the 
normal, occurs without correction of the blood picture (Klose®). 

The influence that the toxic components of a qualitatively altered 
thjonus gland have upon the s^-mptom complex of Graves' disease may 
be established only to a presumptive degree. No doubt the vctgotonia 
observed in certain cases is one of these symptoms. It is also prob- 
able that the degree of lymphocytosis in Graves' disease is not indi- 
cative of the severity of the disease, nor does it mean that the thymus 
gland is playing an increasing part in it. This is none the less so 
because IjTnphocytosis of itself very properly may be regarded as a 
condition of affairs prejudicial to the organism. However, it may 
be considered as certain that the degree of lymphocytosis in Graves' 
disease points to dysthmization and justifies surgical attack upon 

THE THTMU.S GLAXD WHEX A RELATIVELY SLIGHT INCREASE IX THE SIZE 
OF THE THYROID GLAXD IS ATTEXDED V^^TH SEVERE CARDIAC DISTURB- 
ANCES. A faulty conclusion in this connection may be arrived at when 
previous Rontgen ray treatment has caused lessening of lymphocy- 
tosis. The ray treatment may cause an involution of the th}Tnus 
gland from which regeneration does not occur. It would seem best to 
employ the measure for 4;he purpose of postoperative reduction of 
lymphocytosis in Graves' disease. 

Operations on the Thymus Gland. — The surgical treatment of thjTuus 
disease aims at decompression and restriction of its secretion. These 
are attempted in the hyperplasia of childhood. In Graves' disease 
the treatment is directed only toward excluding abnormal secretion. 

In childhood only a portion of the gland may be removed ; in the 



DISEASES OF THE THYMUS GLAND 1783 

adult, it is permissible to extirpate the entire organ. In the adult 
radiotherapy may aceomplish the purpose ; in childhood its employment 
is absolutely contraindicated — the persistent application of the 
method by some notwithstanding. 

All forms of pressure are relieved when the upper pole of the gland 
is resected and its capsule fastened to the sternal fascia. This reduces 
the dimensions of the organ and lifts it from the mediastinum. 

Intracapsular excision and fixation of the thymus gland accomplishes 
the purpose in most instances. When the gland is particularly large, 
the manubrium mmj he resected. This permits the gland to protrude 
and relieves pressure to a sufficient extent, without dangerous reduc- 
tion of its tissue. In very severe cases it is justifiable to perform 




Fig. 843. — Cervical Suspension of Thymus Glaxd (Klose). 



intracapsular enucleation of one of the lohes of the gland. As the left 
lobe is the one most often affected, lies higher, and makes pressure on 
the vagus, it is' the one to be sacrificed. This leaves the larger, right 
lobe to perform the necessary functions. 

Ether narcosis is desirable. An incision about six cm. in length, 
with a slight upward concavity, is made over the lower portion of the 
incisura jugularis, through the skin, and the fiap turned upward. The 
superficial fascia is opened in a vertical direction. The sternal 
muscles are separated, or, if necessary, incised transversely. The fascia 
lying behind these muscles is opened, also in a vertical direction, after 
the veins are carefully tied. This exposes the pretracheal space, in 
which either the pointed ends of both lobes, or only that of the left, 



1784 THE SURGERY OF THE THYMUS GLAND 

covered with the capsule, are found. As the latter is grasped and 
drawn forward, it is seen to be continuous with the sheaths of the car- 
otid arteries and jugular veins. In children it is impossible to extir- 
pate the entire gland. 

As the capsule is opened the parenchyma of the gland promptly 
prolapses into the wound. This is often immediately followed by aboli- 
tion of stridor, and suffices to remove the extruded tissue. If the 
stridor persists, enough of the gland is delivered until this ceases. 
The anterior layer of the gland is sutured to the sternal fascia and 
the wound tamponed. 

Resection of the sternum is executed in accord with general surgical 
principles. The prognosis is favorable. A similar technic is followed 
in cases of Graves' disease. Every strumectomy should be pre- 
ceded BY PALPATION OF THE THYMUS AND THIS, WHEN ENLARGED, RE- 
SECTED (Klose^). 

When the thymus gland is not movable, it must be approached by 
resecting the sternum. 

When the gland "enmantles" the heart, operative attack must be 
performed with proper consideration for differences in pressure (see 
Surgery of the Thorax, Part XV, chap. xvi). A similar method is 
used in removal of tumors of the thymus gland. If this is not feasible, 
the pressure symptoms may be relieved by medimi section of the 
sternum. 

BIBLIOGRAPHY 

1. Hammar. Ergeb. d. Anat. u. Entwick, 1910, xix. 

2. Klose. Neue Deutscli. Chir., 1912, iii, with eomp. lit. 

3. Crottl Thyroid and Thymus, N. Y., 1918. 

4. WiESEL. Ergeb. d. allgem. Path., etc., 15 Jahrg., 2d Abt. 

5. Marfan. Arch, de med. des enfants, 191v'), No. 13. 

6. Klose. Handb. d. prakt. Chir. Bd. ii, Stuttgart, 1913. 



PAKT XIV 

THE SURGERY OF THE ESOPHAGUS 



CHAPTER I 
THE SUBGERY OP THE ESOPHAGUS 

Examination of the Esophagus. — Esophagoscopy has had a sharp 
impetus in the last few years. In March, 1919, Jackson^ analyzed 628 
eases of foreign body removed from the air and food passages. 
Unfortunately, it has been practiced more by the laryngologist than 
by the surgeon. It is impossible to review the history of the develop- 
ment of this branch of surgery here. It had its origin in the work of 
Mikulicz and passed through stages of improvement to the develop- 
ment of the present method of electrobronchoesophagoscopy of Brun- 
ning (see Part XII, chap. v). As a rule, the application of novo- 
cain to the pharynx (especially the sinus pyriformis) is sufficient to 
make the introduction of the instrument bearable ; in special cases, 
narcosis may be employed. Usually, the tube is introduced with the 
patient in the sitting posture. When the constrictors of the pharynx 
are passed, the patient is carefully lowered to the supine position. 
The subsequent advancement of the tube is now easily accomplished. 
If the instrument is halted, the cause must be sought for. When the 
instrument is introduced without the mandarin (which is indicated 
in lesions located high in the esophagus), especial care must be taken 
not to do injury. Recently Ach- has devised an instrument much 
like the proctoscope, which makes possible inflation of the esophagus. 
It is used in retrograde or gastral esophagoscopy and may also be 
used through an esophageal fistula in the neck. It has recently been 
employed in oral examinations and would seem to point the way to 
a field of usefulness of considerable magnitude. 

The employment of esophagoscopy is contraindicated in acute in- 
flammatory processes (except for foreign bodies), emphysema, cardiac 
diseases, aneurism and tracheal stenosis. Esophagoscopy is not an 
ENTIRELY HARMLESS PROCEDURE, but the introduction of the bougie is 
little less so. Infection of the esophageal mucosa, phlegmon, and in- 
vasion of the mediastinum has led to a fatal outcome in several in- 
stances. This means that all manipulations in the esophagus must be 

1787 



1788 THE SURGERY OF THE ESOPHAGUS 

carefully executed. The entrance of the esophagus, especially in 
eases of carcinoma, presents the zone of greatest danger in this con- 
nection. 

The field of usefulness of the method includes the removal of and 
localization of foreign bodies, and has a diagnostic and therapeutic 
value. 

The diagnostic value pertains to visualizing various lesions, such as 
new growths, ulcers, strictures, dilatations, etc., and their localization. 
In addition to this, portions of tissue may be removed for microscopical 
examination. Therapeutically , the method permits of the local treat- 
ment of dilatations, strictures, etc., and the opening of abscesses, etc. 

Radioscopy is of great diagnostic assistance. See Foreign Bodies, 
Strictures, etc. 

Auscultation reveals two "deglutition sounds" audible over the 
posterior aspects of the left ninth and tenth dorsal vertebrae. The 
first is heard immediately after the act is produced by the downward 
projection of fluids. The second is produced by the passage of food 
through the cardia and is audible six or seven seconds after the act 
of deglutition. The presence of an obstruction is indicated by a modi- 
fication in these sounds and by delay in their production (Meltzer*). 

In hougie examination of the esophagus three normal areas of nar- 
rowing must be taken into account. The upper one is located at the 
beginning of the esophagus, the lower one at the hiatus, and the 
middle one corresponds to the bifurcation of the trachea. These are 
the points where foreign bodies are most likely to be arrested and 
where the greatest number of lesions are located. 

Bougie examinations must be executed with gentleness. The Eng- 
lish and French fabric and shellac bougies are best adapted for the 
purpose. When the presence of a diverticulum is suspected, a bougie 
fashioned like a Mercier's urethral catheter may be used to advan- 
tage. The angulated tip is expected to pass the entrance into the 
diverticulum. Before introducing the bougie, false teeth must be 
removed, and the presence of an aortic aneurism must be excluded. 
Flexible bougies are best inserted with the patient seated; the head 
should be slightly flexed, thus increasing the diameter of the entrance 
of the esophagus. The left forefinger holds the base of the tongue 
forward and the right hand carries the bougie against the posterior 
pharyngeal wall. The patient is instructed to breathe deeply and 
then the bougie is slowly advanced into the esophagus. The manuever 
is not a difficult one. The bougie should be sterile. 



THE SURGERY OF THE ESOPHAGUS 1789 

Congenital Malformations of the Esophagus. — Complete absence of 
the esopJiagus is very rare. 'Total atresia is also uncommon. Of the 
malformations, separation of the esophagus into two parts is the most 
common. The upper portion ends in a blind pouch which is distended, 
not unlike a diverticulum, and ends in the region of the jugulum. 
Occasionally' it communicates with the trachea by means of a fistula. 
The lower rises from the stomach, is often very short and narrow and 
terminates in a blind end or opens into the trachea, the posterior wall 
of which may be absent. The malformation is due to developmental 
anomolies of the esophagus and trachea (Kreuter*). Children afflicted 
in this way become cyanotic when food is taken. The food flows out 
of the mouth and a fatal outcome ensues in about thirteen days. Gas- 
trostomy and exclusion of the cardia have b,een practiced by v. 
Hacker.^ The latter is intended to prevent food from gaining access 
to the trachea from below. If the child survives the operation, an at- 
tempt may be made to make an antethoracic esophagoplasty. If the 
blind ends of the incomplete esophagus lie sufficiently close together, 
an effort may be made to tunnel the space (TTiomas®). 

Injuries of Esophagus. — Injuries of the esaphagus from within 
are produced by swallowing or introducing foreign bodies, which in- 
clude bougies, coin catichers, and the esophagoscope. Injury from the 
esophagoscope occurs especially in- cases of carcinoma, ulceration, and 
stricture of the gullet. Perforation of the esophagus is followed by 
invasion of the mediastinal or plural cavities by infectious processes. 

Burns of the esophagus are discussed elsewhere (p. 1687), 

Stah, incised and gunshot wounds involve the esophagus from with- 
out. They are not frequent and are usually a part of severe injuries 
of the contigvuous tissues. In the neck a distinction between injuries 
of the pharynx and of the esophagus has no significance. 

In the neck the trachea is usuallj^ injured at the same time. In not 
a few instances the thyroid gland and the large vessels and nerves are 
injured, especially in gunshot wounds. In the latter in>stance, the 
spine and the spinal cord are often involved. The esophagus alone 
is liable to be injured in stab and in gunshot wounds. 

In gunshot mounds of the neck, the esophagus may not be opened, 
but may be perforated from ulceration of a severely contused area. 
A gunshot wound of the esophagus is always a severe injury. This is 
ascribed, in part, to the coincident complications, of which infection of 
the mediastinum is not the least common. This would seem to justify 
exploration in doubtful cases. 



1790 THE SURGERY OF THE ESOPHAGUS 

Incised wounds of the esophagus occur most often in connection with 
attempted suicide. Unless the wound is very small the egress of food 
makes the diagnosis. Simultaneous injury of the trachea has already 
'been taken up (p. 1705). 

The treatment of choice consists in immediate closure of the esopha- 
geal wound by suture. For the purpose, a double row of Lembert 
sutures is used. This is imperative, irrespective of whether the outer 
wound is closed or not. Even though complete primary union is not 
obtained, the period of healing is much shortened. When the trachea 
and esophagus are completely divided, . circular repair by suture is 
indicated. 

External esophageal fistulae follow isolated injury of the esophagus 
and the simultaneous injury of the food and air passages in the neck. 
External esophageal fistula is rare. On the other hand, a communica- 
tion between the gullet and trachea is not uncommon. The former 
usually heals spontaneously. Simultaneous injury of the esophagus 
and trachea rarely leads to the formation of stricture, but fistula for- 
mation is very likely to follow. Of these, laryngopharyngeal fistula, 
with one or two external openings, is the most common. In these cases 
permanent use of the tracheotom}^ tube may be necessary. These ex- 
ternal fistulae must not be confused with the persistence of an internal 
communication between the esophagus and trachea following injury. 

The treatment of external esophageal fistula becomes necessary when 
the opening persists; this is the case when the mucosa is adherent to 
the opening in the skin. Closure may be attained in cases of moderate 
degree by refreshening the edges of the opening and subsequent suture 
When there has been much loss of substance, plastic repair of the defect 
may be necessary. In the latter instance, temporary gastrostomy pos- 
sesses decided advantages. In cases of simultaneous fistulae of the 
gullet and air passage the technical difficulties pertain to the latter. 
In any event, an attempt should be made to close the opening into the 
esophagus first. In esophagotracheal fistulae the lesion must be widely 
exposed and repaired separately (v. Hacker^). 

Injuries of the thoracic esophagus do not present a distinct clinical 
picture unless it happ'ens that food emerges from the external wound. 
As a rule, the injury occurs in connection with an injury of other 
parts or organs, especially of the lungs. In the latter event, the tissues 
are emphysematous. The diagnosis is obscure, although the vomiting 
of blood, localized pain during deglutition, and perhaps the esopha- 
goscopic picture may lead to the correct conclusion (Hochenegg*). The 



THE SURGERY OF THE ESOPHAGUS 1791 

treatment is ziot satisfactory. A teiupurary gastrostomy is justified on 
the ground that the undisturbed esophageal lesion may heal. Tam- 
ponade (with a string attached) of the esophagus through the esophag- 
oscope has heen suggested by v. Hacker.^ Complicating mediastinal 
and pleural infections must be treated by aspiration and drainage 
(Part XV, chap. v). 

Rupture of the esophagus occasionally occurs spontaneously. How- 
ever, an underlying pathological condition may exist without being 
discovered (Mackenzie'*). A certain number of cases are undoubtedly 
of traumatic origin, e. g., those resulting from violent vomiting. 

Perforation of the esophagus, aside from invasion of the tube from 
without, occurs in connection with ulcerative and other destructive 
processes, such as tuberculosis, carcinoma, etc. 

Esophageal hemorrhage is likely to appear in connection with al- 
most all of the pathological processes occurring in this region and is 
of importance chiefly because of the necessity of differentiating it, 
when feasible, from gastric bleeding. Persistence of the hemorrhage 
demands temporary gastrostomy. Oral or retrograde tamponade may 
be made. 

Foreign Bodies in the Esophagus. — Jackson V resume of the character 
of foreign bodies that have lodged in the esophagus leaves little to the 
imagination. From a practical standpoint this includes anything that 
may be forced past the entrance of the esophagus by the act of degluti- 
tion or -by manipulation. As an illustration- of the futility of any 
effort to go into detail in this connection, one may mention the case of 
an insane person who swallowed a copper crucifix (quoted by v. 
Hacker") . The religion of the patient is not stated. In a general way, 
foreign bodies may be divided into those with rough, pointed or sharp 
surfaces which cause injury, and those that are smooth and cause only 
obstruction. 

The points at which foreign bodies are arrested depends upon the 
size of the latter. Small pointed objects may be fixed at an}^ point of 
the gullet ; very large ones rarely pass the isthmus, but remain in the 
pharynx. However, the former may be caught in the mucosa of the 
latter. Bodies of moderate size that pass the pharynx are most likely 
to be arrested at the three points of normal narrowing. By far 
the largest number of bodies are arrested at the thoracic aperture; 
those located below are usually forced downward by swallowing firm 
articles of diet or by the bougie. Those passing farther down are 



1792 THE SURGERY OF THE ESOPHAGUS 

arrested at the hiatus, almost never at the cardiac opening into the 
stomach. When the hiatus is passed the body enters the stomach. 

The symptoms of foreign hodies m the esophagus depend upon their 
location, the distortion they cause in the ^llet and the degree of con- 
sequent pressure upon neighboring organs (lar^mx and trachea) and 
upon whether they provoke ulceration and perforation or not. A body 
located behind the larynx causes respiratory disturbances. 

In complete high obstruction, food is immediately regurgitated; in 
low obstruction, it is retained for a brief period of time. Sharp pain 
upon deglutition indicates that the foreign body has impinged upon 
the wall of the gullet. As a rule, patients are able to swallow fluids. 

The consequences of the lodgment of a foreign body in the eso- 
phagus also differ widely. As a rule, they are serious unless relief 
is afforded by extraction, by offending agent's entering the stomach, 
or by its being expelled by vomiting. Blood is expelled through the 
mouth only when the body is located high up ; the bleeding is rarely 
severe. Abscess formation is not uncommon. Ulceration, perforation, 
and infection of contiguous parts form a frequent sequence of events. 
Secondary invasion of this sort of the air passages leads to a menacing 
condition of affairs. Involvement of the mediastinal spaces, the 
pleura and the lung occurs in a certain proportion of the cases (Gers- 
ter^°). 

The diagnosis may usually be made on the symptoms. In their 
absence, the statements of the patient may not be relied upon. A more 
or less complete physical examination with negative findings has, on 
more than one occasion, terminated in discovering supposedly swal- 
lowed false teeth on the floor of the patient's bathroom or elsewhere. 
The pharynx and its vicinity may be examined directly. Large bodies 
located in the cervical region may often be palpated through the tis- 
sues of the neck. Secondary inflammation gives rise to pain and 
tenderness in this region. Rapid increase in the size of the thyroid 
gland (acute strumitis) often attends the presence of a foreign body 
in the cervical portion of the esophagus. It is ascribed to absorption 
of infectious substances. 

The Rontgenographic examination is of the greatest value. Care 
must be taken in interpreting the negatives, so that calcareous deposits 
are not mistaken for foreign bodies. If the radiographic findings are 
positive, the passage of the bougie is unnecessary or perhaps unjusti- 
fied, as the bod}^ maj^ change its position at any time. Efforts at ex- 
traction must be made immediately after the radiographic examination. 



THE SURGERY OF THE ESOPHAGUS 



1793 



Extraetioii of smooth, moderate sized bodies (coins) has been ac- 
complished with the umbrella sound under the guidance of the fluor-- 
oscope (Heurad" — twenty-one cases). Careful sounding of the eso- 
phagus is of diagnostic value, although its field of usefulness has been 
much restricted by the radiographic and esophagoscopic examinations. 
The first should be used only when the last two are not available. A 
flexible (non-metallic) bougie should be employed for the purpose. 

Removal of Foreign Bodies.^ The removal of foreign bodies 
from the esophagus may be divided into bloodless and hloodij methods. 
The former is accomplished by means of the esophagoscope, and, if 




Fig. 844. — Eontgenogram of Foreign Body (safety pin) in CERViCAii 
Esophagus (Harlem Hospital case). 

this is not available, by direct instrumentation. By both methods, the 
body may either be withdrawn or forced into the stomach. 

Extraction hy means of the esophagoscope is the most desirable 
method and often succeeds after other means have failed. It is es- 
pecially indicated when the body is located above a stricture, in which 
event instrumentation is not successful in moving it in either direc- 
tion. Killian^^ has succeeded in reducing the size of a prosthesis with 
the galvanocautery, after which it was readily pushed into the stom- 
ach. This has also been accomplished with the crushing forceps. 

Direct instrumental removal through the mouth without esophag- 
oscopy is likely to be attended with considerable danger. The danger 
is somewhat less when the bod}^ is smooth and flat. The purpose may 



1794 THE SURGERY OF THE ESOPHAGUS 

be accomplished hy means of forceps or b}' instruments intended to pass 
the object and remove it as they are withdrawn. Of these instruments, 
the expanding probang (Fig. 845) is universally used. The instru- 
ment is introduced in its conical form. After passing the object the 
portion armed with twisted bristles is caused to expand and upon its 
withdrawal is expected to bring the offending substance with it. Small 
objects may often be removed in this way. Nevertheless, the method 
is very properly regarded as "a gamble." Forcing hodies into the 
stomach by means of indirect instrumentation is permissible when the 
obstruction is caused by soft substances, such as meat or potatoes, or 
by smooth, hard substances. An ordinary flexible bougie may be used 
for the purpose. 

Operative methods are indicated when the others have failed or are 
primarily eontraindicated. They may be divided intf) pharyngotomy, 
trachelotomy lateralis, gastrotomy, and thoracic esophagotomy. 

T£MAm-CO NY 




Fig. 843. — Exp.\NDiNG Esophageal Probang 



Pharyngotomy is described in connection with the surgery of the 
larynx (p. 1695). 

Lateral trachelotomy for exposure of the esophagus, i. e., without 
opening the latter, is practiced when it is possible to manipulate the 
foreign body in the pharynx and extract it — the advisability of which 
measure goes without saying. If this is not feasible, the esophagus is 
opened. The incision is made on the left side and corresponds in every 
particular to that employed for exposure of the common carotid 
artery, except that the omohyoid muscle is usually divided. The 
sheath of the vessels is drawn outward and the thj-roid gland is drawn 
toward the median line. If necessary, the inferior thj'roid arterj^, as 
it passes behind the carotid, is divided between two ligatures. The 
esophagus is readilj- identified by its longitudinal fibers, or the bulging 
foreign body very often discloses its location. The gullet is now 
opened, fixed with suture loops, and the foreign body extracted with 
the forceps. The esophageal wound is sutured only when its edges 
are not traumatized by the manipulations. The repair is made with 



THE SURGERY OF THE ESOPHAGUS 1795 

a double row of Lembert sutures. Complete primary union is rare. 
In either event, the external wound is drained. The establishment of 
a temporary osophageail fistula is necessary only in the presence of 
infection. A tube is immediately introduced into the stomach through 
the nose for the purpose of nourishing the patient. Sterile food is 
given for eight days. Permanent esophageail fistula is exceedingly 
rare. 

Gastrotomy for the purpose of removing a foreign body from the 
esophagus is employed when the body is located 25 to 27 cm. below the 
teeth. The use of the esophagoscope has made this a rare operation. 
The abdomen is opened through the left rectus muscle ; a purse string 
suture is introduced into the anterior wall of the stomach as near the 
cardia as possible ; within this a small incision is made ; the finger is 
introduced into the esophag-us and the foreign body is ''fished out." 
If this does not succeed, a string is passed into the stomach from 
above by means pf a slender bougie. The former is delivered through 
the abdominal wall and a pledget of gauze tied to its oral end which 
is drawn downward ; the maneuver is expected to drag the body into 
the stomach. The rule of the day is to expose the stomach freely, 
open widely in a longitudinal direction, introduce the gloved hand, 
and achieve the extraction with the fingers (Wood^^). Gastrotomy 
is employed for the removal of foreign bodies located in the grasp of 
a stricture when the latter is to be simultaneously divided by the 
string method. 

In thoracic esophagotomy dorsalis the gullet is approached through 
the posterior mediastinum. The method is very complicated and has, 
as yet, not proved satisfactory. The newer methods of opening the 
thorax under differences of pressure hold out a certain degree of hope 
for the future in this connection. See Surgery of the TTiorax, Part 
XV, chap. vi. 

The treatment of the coTnplications of foreign bodies in the esopha- 
gus is of importance. Bleeding from the traumatized gullet or the 
result of ulceration demands immediate external esophagotomy and 
tamponade of the bleeding zone after the body has been removed. 
The prognosis is unfavorable, especially if the bleeding occurs from 
ulcerative perforation of a large vessel in the neck (Gerster^"). The 
treatment of retropharyngeal abscess does not differ from that em- 
ployed when the process is due to other causes. This is equally true 
with regard to a complicating phlegmon of the neck. It is of prac- 
tical value to note that purulent pleuritis, pneumonitis, etc., may begin 



1796 THE SURGERY OF THE ESOPHAGUS 

in the comiective tissue surrounding the esophagus and that the process 
may extend to the neck, thus forming part of an abscess cavity of 
enormous dimensions. The advent of these processes is attended with 
the clinical picture of a septic process. Its localization must per force 
be established by painstaking examination of the patient. Evacuation 
of the pus is of course imperatively indicated and is difficult only when 
the mediastinum is invaded. 

Inflammatory Diseases of the Esophagus. — Acute and chronic catar- 
rhal inflammatory diseases of the esophagus are of surgical importance 
only in as much as the pathological processes with which thej' are 
attended must be taken into account in interpreting the esophago- 
scopical picture. Cfcronic inflammations often complicate esophageal 
diverticula and esophageal spasm. The importance of necrotic and 
diphtheritic inflammations lies in their tendency to be followed by 
the formation of strictures. Phlegmonous esophagitis begins in the 
submucosa and occasionally may be diagnosticated when dysphagia is 
attended with the symptoms of fever which suddenly clear up after 
pus is vomited. Suspicion of the condition would seem to justify 
the careful introduction of the esophagoscope, through which the area 
might be incised. 

Toxic or corrosive esophagitis, which follows the ingestion of corro- 
sive substances, is of surgical importance because the swelling of the 
tissues may demand gastrostomy and later because of the sequential 
strictures that are formed. In severe cases in which the stomach is 
involved, the question of jejunostomj^ ma}^ come up. 

Ulcers of the esophagus are due to various causes, of which tuber- 
culosis and lues are the most frequent. 

Luetic xdcers are comparatively rare; they occur most often in the 
upper portion of the esophagus. The process is, usually, primarily 
gummatous. Tliis breaks down, and the repair is followed by more 
or less narrowing of the lumen of the gullet. Their presence is dis- 
covered with the esophagoscope and must be differentiated from tuber- 
culosis, actinomycosis and carcinoma. The therapeutic test is valuable 
in this connection. 

Tiihercidous idcers have only recently been recognized. They occur 
in connection with tuberculosis elsewhere in the body, especially that 
of the air passages (inoculation from swallowed sputum). The bibli- 
ography is collected by Gardere" and Guisez.^^ The former has col- 
lected 70 cases. 



THE SURGERY OF THE ESOPHAGUS 1797 

Actinomycosis of the esophagus should be borne in mind in connec- 
tion with ulcerative processes in this situation (Garde^^). 

Peptic, or round, ulcer of the esophagus develops, as is to be ex- 
pected, at its lower end. It is of importance because of the possibility 
of the development of pleuritis, peritonitis, etc. 

Refinements in diagnosis in. connection with the character of ulcera- 
tive processes in the esophagus have been made possible by the emplo}'- 
ment of the esophagoscope. There is no doubt that a closer scrutiny 
of cases of disturbances in deglutition will lead to a justification of 
this method of examination. The practitioner is asked not to dismiss 
his cases of so-called "heartburn" without taking the possibility of 
an esophageal lesion into account. Of course, the indiscriminate use 
of the method is to be deprecated. However, in properly selected 
cases it often clears up an obscure condition and makes relief possible. 

Strictures of the Esophagus. — Of the causes which narrow the esopha- 
geal passage, those originating in connection with lesions of the walls 
of this organ are of surgical importance. These are genuine strictures 
and may be di\'ided into congenital, inflammatory, spastic, cicatricial 
and neoplastic. However, in the differential diagnosis the surgeon 
must take into account the so-called compression stenoses which are due 
to enlargement or displacement of neighboring organs or parts. Of 
the various strictures of the esophagus, those caused by carcinoma and 
corrosive agents are the mOvSt frequent. 

A conception of the conditions presented by strictures of the esopha- 
gus may be based upon those occurring as a sequel to the action of 
corrosive agents. These vary w^idely in extent, carrying out an accord 
with the degree of destruction of tissue, and thus correspond in a great 
measure to the strictures following the healing of other destructive 
processes. It should not require a great effort to visualize the processes 
concerned in the production of a cicatricial stricture of the esophagus 
from the viewpoint of the formation of scar tissue in- any portion of 
the body — the urethra, the rectum, the skin, etc., especially when the 
deformations occurring in connection with extensive destruction of the 
last is borne in mind. That these deformations varj' in extent and 
outline is to be expected, so that it is quite rational to classify them as 
linear, semilunar, annular and tubular. The annular and semilunar 
form, which offer great resistance to the passage of food, cause the 
upper segment of the gullet to dilate to a greater or less extent and 
its muscularis to become hypertrophied. The greatest degree of 

STENOSIS OF THE ESOPHAGUS OCCURS AT ITS BEGINNING, AT A POINT OPPO- 



.1798 



THE SURGERY OF THE ESOPHAGUS 



SITE THE BIFURCATION OF THE TRACHEA, AND IN THE REGION OF THE 

HIATUS. It seems hardly necessary to add that a stricture may cause 
complete or incomplete stenosis of the esophagus. 

It is of practical importance to note that the dilated portion of the 
esopha^s, in accord with the degree of stenosis, is the seat of chronic 
irritation, and the formation of diverticula is the outcome of retained 
articles of diet which undergo decomposition. 

The main symptom, of stricture of the 
esophagus consists in difficulty in deglu- 
tition which, in a general way, cor- 
responds to the degree of obstruction. In 
slowly developing obstruction, the in- 
ability to swallow becomes gradually 
manifest ; immediate regurgitation of in- 
gesta argues for a high obstruction ; their 
retention for several seconds indicates 
stenosis lower dowTi. When the obstruc- 
tion develops gradually, the patient is 
able to propel food into the stomach in 
small quantities at a time. The retention 
of a considerable quantity of food and its 
sudden expulsion, together with mucus, 
saliva, etc., indicates that the esophagus 
is dilated above the stricture. As a rule, 
fluids maj- be ingested .after solids and 
semisolids are rejected. 

The diagnosis of the presence and seat 

of a stricture is best established with the 

tougie. A description of the method has 

been given (p. 1781). After this is done, „,,.„, 

^ t , T • 1 1 Tube m false passage m 

the esophagoseope may be used, with the thoracic portion (v. Hacker). 

view of determining the exact character of 

the obstruction. The Rontgenographic examination is very helpful. 

The differential diagnosis between a cicatricial and carcinomatous 
stricture is readily made with the esophagoseope, especially when a sec- 
tion is removed and subjected to microscopical examination. The rarer 
forms of stricture already mentioned must be borne in mind, especially 
the luetic. 

The prognosis in cicatricial strictures depends upon the degree of 
stenosis and upon the extent of the surface involved. Restitution to 




Fig. 846. — Tubular Stricture 
OF Esophagus Extending 

FROM CARDIA to BIFURCA- 
TION. 



THE SURGERY OF THE ESOPHAGUS 



1799 



the normal caliber of the esophagus is never attained; a functionally 
adequate lumen is as much as may be expected, and this only when 
dilatation is indefinitely persisted in. If the latter is omitted, the 
stricture recontracts. 

The treatment of esophageal strictures (aside from those located in 
the cervical region, which may occasionally be resected, and those near 
the cardia, which are treated by interthoracic esophagogastrostomy) 

aims at dilatation of the stenosis. 
The two methods employed are 
bloodless dilatation with bougies 
and the operative treatment. 

Dilatation is ushered in by the 
examination with the bougie, which 
determines the degree of narrow- 
ing and gives an index of the extent 
of the necessary stretching. The 
method is very simple and consists 
in the successive introduction of in- 
creasingly larger bougies. Patience, 
persistence, and gentleness on part 
of the surgeon, and cooperation on 
part of the patient are essential to 
success. At first, the bougie is left 
in situ 5 to 10 minutes ; later, for 
half an hour. Dilatation need not 
be carried beyond 13 to 14 mm. in 
diameter. In narrow stricture a 
filiform guide may first be inserted 
Fig. 847.— Esophageal Bougie In- ^nd a tapered hollow bougie intro- 

TRODUCED OVER FILIFORM GUIDES ^ . o ^ rr x 

(v. Hacker). duced over it (Fig. 847). A de- 

scription of the refinements of the 
instrumentarium cannot be included here. While the esophagoscope 
gives valuable information with regard to the character and extent 
of the process under consideration, it does not add anything to the 
technic of the bougie treatment of strictures. As a rule, the obstruc- 
tion lies at a point beyond the area of the lesion made visible by this 
instrument. The local and general use of fihralysin has not yet 
proved of value. 

The Operative Treatment of Esophageal Strictures. — Caustics 
may be applied to strictures through the esophagoscope. The appli- 




1800 THE SURGERY OF THE ESOPHAGUS 

catiou of the corrosive fluid or the electrocautery is justified only in 
ulcerative stenoses or when a stricture is valvular in shape. The 
method must be immediatel}^ followed by bougie dilatation. 

Electrolysis is employed by introducing through the stricture a metal 
sound which corresponds to the negative pole of the current ; the posi- 
tive pole (a metal plate) is applied to the anterior thoracic wall and 
an electric current of about 15 ma. is allowed to flow for from 50 to 
60 seconds. The method seems to possess some value (Newmann ;^^ 
see also report of Guisez^'^'). 

Internal esophagotomy by means of cutting instruments (on the 
order of the urethrotome) introduced from above is no longer prac- 
ticed because of the dangers coincident with the procedure. Discission 
of a diaphragm-like stricture through the esophagoscope is permissible. 
Guisez/^ who had two fatalities in seventeen cases, has abandoned the 
method in favor of electrolysis. 

External cervical esophagotomy, i. e., opening the gullet in the neck, 
is practiced when the lesion is situated at this portion of the tube or is 
resorted to in order to make those lower down more readily accessible. 
The exposure is made for the purpose of (1) extirpation of a stric- 
ture; (2) discissian of a stricture; (3) estahlishment of an esophageal 
feeding fistida. When the stricture is located below the thoracic 
aperture (more than 20 cm. below the teeth in the adult), cervical 
esophagotomy or temporary esophagostomy is practiced for the pur- 
pose of dilating the stricture or as a step in combined esophagotomy. 
The technic of esophagotomy is similar to that described in connection 
with removal of a foreign body. After the esophagus is opened, the 
stricture is divided in a longitudinal direction. The external wound 
is tamponed so that a temporary eso-phageal fistula is established. 
The lips of the wound in the gullet may be sutured to the skin and a 
tube passed into the stomach. The fistula may be used as a permanent 
means of feeding the patient in cases of impermeable stricture or in 
carcinoma. 

In combined esophagotomy the gullet is opened in the neck above 
the stricture and the latter is divided with a herniotomy knife passed 
through the opening. A tube is introduced and left in situ for several 
daj^s. The method is used when the stricture is located below the level 
of the tracheal bifurcation. It has not found favor. 

Complete circidar resection of a strictured segment of the cervical 
esophagus is indicated when the exposure is adequate and the stenosis 
is impermeable. The ends of the divided gullet are united by circular 



THE SURGERY OF THE ESOPHAGUS 1801 

suture. The operation is an extensive one. In order to prevent 
infection of the neck wound, temporary gastrostomy is advisable. 

Gastroiomj/ for retrograde dilatation of esophageal stricture is rarely 
practiced at this time. 

Gastrostomy is frequently employed in connection with obstinate 
strictures located deep in the esophagus. However, it is indicated only 
in cases in which the stricture remains impermeable to efforts directed 
from above (v. Hacker'*). The method is used for retrograde dilata- 
tion of the stenosis, especially when inanition is threatening, as the 
fistula permits of feeding the patient. The fistula should be made as 
small as possible and should be arranged so that spontaneous healing 
occurs after the stricture is sufficiently dilated. After the ga.strostomy 
opening has persisted for several weeks, it is often possible to pass a 
filiform guide into the stomach from above and withdraw it from 
below, or the reverse. Once this is accomplished, the use of the hollow 
bougie is comparatively easy. Various ingenious methods of establish- 
ing communication between the mouth and the fistula have been 
devised; of these the string method (Abbe^^) is as satisfactory as any. 
The string, with a small ball attached, is swallowed and ' ' fished out ' ' 
of the stomach. The introduction of a bougie through the gastric 
fistula into the esophagus and retrograde dilatation are facilitated by 
the use of the gastroscope, w^hich is not unlike the cysto-urethroscope in 
construction. In a certain number of cases esophageal instrumenta- 
tion is made more effectual through a cervical fistula established for 
the purpose. In all cases in which oral dilatation does not suc- 
ceed, AN EFFORT MUST BE MADE TO ACCOMPLISH THE PURPOSE THROUGH 

A GASTROSTOMY (not a gastrotomy) opening. 

Transpleural esophagogastrostomy is an exceedingly complicated 
operation designed for the resection of portions of the thoracic esopha- 
gus. The thorax is opened in the manner described in Part XV, chap. 
vi (Meyer^^). 

Transperitoneal esophagogastrostomy is another diffi^cult operation 
devised for the purpose of excising strictures located near the hiatus. 
Of the various methods, which include resection of ribs and the forma- 
tion of thoracic osteoplastic flaps, that of transdiaphragmatic approach 
would seem to hold out the best chances of success (Heyrovsky^^). 
The surgeon should be certain that the indications for an operation of 
this magnitude are clearly defined before exposing the patient to the 
attendant risks. 

Exclusion of the Entire Thoracic Esophagus — Antethoracic 



1802 THE SURGERY OP THE ESOPHAGUS 

EsoPHAGOPLASTY. — In cases of impermeable stricture an efifort has 
been made to exclude the thoracic esophagus by antethoracic esophago- 
plast}^ (v. Hacker,-^ Meyer,-'-^ Trendelenburg'"^). The methods of 
accomplishing the purpose are: 

1. Antethoracic dermato-esophagoplasty. 

2. Antethoracic entero-esophagoplasty. 

3. Antethoracic dermato-entero-esophagoplasty. 

In antethoracic dermato-esophagoplasty (Bircher-*) the cervical 
esophagus is delivered through the neck and connected by suture with 
a tubular canal fashioned from two layers of the skin of the anterior 
thoracic wall. This dermatogenous tube is connected with the anterior 
wall of the stomach by drawing a fold of the latter through a wound 
in the anterior abdominal wall and making an end to side anastomosis. 
The likelihood of failure is, to say the least, not remote. 

Antethoracic entero-esophagoplasty , esophagojejuno-gastrostomy 
(Rdux^'^'), consists in isolating a loop of jejunum, implanting its anal 
end into the stomach and later connecting it with the cervical esopha- 
gus. See Bibliography of v. Hacker.^ 

In antethoracic dermato-entero-esophagoplasty ("VVullstein^") the 
upper segment of the vicarious tube is made, as in the first method, and 
this is connected with a loop of jejunum, which in turn is anastomosed 
to the jejunum, excluding the thoracic esophagus and the stomach from 
digestive function (v. Hacker'). 

Dilatation of the Esophagus. — Dilatations of the esophagus, as already 
stated, occur above the site of stenosis of various kinds. They also 
develop when there is no discernible lesion. While no doubt most of 
the cases are congenital in origin, distitrhances of innervation would 
also seem to be a causative factor (cardiospasm). The spasm of the 
cardia may be reflex. The vagus, so often accused, would seem to be 
exonerated by the investigations of Gottstein^'' and of others. 

The symptoms are those of esophageal obstruction plus "cramp in 
the gullet." These disappear as soon as the esophagus is emptied 
downward or by regurgitation of its contents. An attack may last for 
several hours. The food retained undergoes decomposition, which pro- 
vokes foul smelling eructations. Many cases go to autopsy without 
being recognized. On the other hand, cardiospasm and dilatation of 
the gullet have been diagnosticated in cases of carcinoma and ulcera- 
tion in this situation. The obstinate persistence of so-called gastric 
indigestion should arouse suspicion of the condition. 

Examination with the bougie is indicative when the instrument may 



THE SURGERY OF THE ESOPHAGUS 1803 

be carried ovor wider than normal excursions in a rotary direction. 
Very often a large bougie enters the stomach, while a smaller one is 
arrested in a smaller sacculated dilatation. As a rule, unaltered food 
may be aspirated. The (juantity of returned fluid is indicative of the 
degree of dilatation. It may be as much as a liter. Esophagoscopic 
and Rdntgenographic findings are of determining diagnostic import. 
In the treatment the first consideration is to prevent the accumula- 
tion of food. This is accomplished by lavage. Progressive dilatation 
of the cardia is at times curative. A temporary gastrostomy makes 
the bougie treatment more effective. A Sym'onds' bougie may be left 
in situ over night. Tlie application of electrolytic stimulation to the 
spasmodic cardia and the administration of atropin are advised by 
Kaufmann and Kienbock.^* If the cardia is accessible to the bougie, 
its dilatation may be practiced (Lerche^"). 

Posterior mediastinotomy and plicatimi of the esophagus has been 
performed by Meyer-- in several instances. It is a procedure of mag- 
nitude. Forcible dilatation of the cardia through a gastrotomy open- 
ing has proved effectual (Erdmann^"). Suhdiaphragmatic esophago- 
gastrostowii is practiced by Heyrovsky.^" 

Diverticula of the Esophagus. — The term diverticulum is applied to 
a restricted sacculation of the esophagus. When the protrusion is 
lined by mucous membrane, the term true diverticulum is used ; when 
the former is absent the term false diverticulum is employed. True 
sacculations are divided into pressure and traction diverticula. 

Pressure diverticula are subdivided, according to their seat, into 
those located at the pharATigo-esophageal junction and those more 
deeply situated. 

Pharyngo-esophageal diverticida are located, as their name implies, 
in the neck, and originate from the posterior lateral (left) wall of the 
gullet at a level wnth the cricoid cartilage. They appear as pear 
shaped sacs and may reach a length of 13 cm., thus obtruding into the 
thoracic cavity. The opening communicating with the esophagus 
varies in size. The diverticulum usually possesses a thickened wall, 
which consists of the h^T^ertrophied layers of the esophagus. 

The causation is undoubtedly pressure from within. However, there 
is no doubt that the congenital lack of muscle fibers at the posterior 
aspect of the pharyngo-esophageal junction is the responsible under- 
lying causative factor. Any condition of the neck, such as struma, 
which favors the retention of food in this situation, may be regarded 
as a determining cause of the condition. According to Lotheisen,^^ 



1S04 



THE SURGERY OF THE ESOPHAGUS 



nervous persons subject to spasm of the pharynx are likely to develop 
the lesion. 

The symptoms do not appear until the sacculations reach a certain 
size. These may consist simply in frequent expectoration of tenacious 
mucus, which often leads to the belief that a lesion of the larjmx is 
present. However, most cases are afflicted with eructations, nausea, 
and vomiting of moderate quantities of ingesta. The last sj-raptom 
is usually regarded as evidence of gastric disturbances. As the 




Fig. 848. — Eontgenogram of Pharyngo-esophageal Di\t:rticulum. 

diverticulum increases, all the ingesta are regurgitated (Butlin^^) . At 
this time swelling becomes palpable at the left side of the neck. This 
may often be emptied by pressure, the food being forced back into 
the mouth. When the diverticulum cannot be emptied, the food decom- 
poses and gives rise to distress and vomiting. At times the swelling 
in the neck gives the impression of a goiter. 

The diagnosis may often be made by the history of gradually increas- 
ing difficulty in swallowing, and regurgitation of unaltered food. 
This is, of course, strongly supported by intermittent swelling of the 



THE SURGERY OF THE ESOPHAGUS 1805 

neck. Examination with the boug^ie, especially when its end is pal- 
pable in the neck, is helpful (Butlin^^) -php diagnosis may be made 
certain with the csophagoscope. Lotlieisen^^ uses an especially con- 
structed instrument for the purpose. The Rontgenogram is of signal 
service. (Fig. 848). 

The treatment consists of operative extirpation of the diverticulum. 
When the patient is much reduced, this may be preceded by temporary 
gastrostomy. The technic of exposure is similar to that of esoplia- 
gotomy cervicalis lateralis (p. 1794). The diverticulum is amputated 
and the opening closed with two layers of Lem'bert sutures, using a 
cutT of the adventitious sac for the purpose; the inverted neck of the 
sac forms a valve which obviates leakage (Lexer^^). In a certain 
number of cases diverticula become the seat of ulcerations which later 
develop malignant disease (Pitt,*^ Starck^'')- 

In deep seated diverticula, the clinical picture (except for swelling 
in the neck) does not differ from that described in connection with 
those located in the neck. As a rule, the diagnosis is doubtful until 
the esophagoscopic and Rontgenographic findings establish the true 
condition of affairs. No doubt a certain number of cases, at first 
regarded as gastric, upon closer study would be recognized as diverti- 
cula of the esophagus. This is shown by a routine series of complete 
Rontgenographic examinations .of the entire digestive tract made by 
Caldwell (personal communication), wdiose untimely death prevented 
publication of 'his work in this connection. 

Lavage of the diverticulum and hougie dilatation of the normal tract 
improves the general condition of the patient. The establishment of 
a feeding gastrostomy is justified. Tlie operative approach is similar 
to that described in connection with stricture (p. 1797). Ablation of 
the sac is accomplished as in cervical diverticulum (Spivek^^). 

Traction diverticida rarely produce symptoms. They occur in con- 
nection with ^chronic inflammatory processes involving contiguous 
parts, organs, and tissues. Of these, tuberculous IjTnphadenitis is the 
most frequent ; the cicatricial contraction coincident with the lesion 
drags out a portion of the esophageal wall which later becomes saccu- 
lated from internal pressure. The literature on the subject is not 
extensive. That of v. Hacker^ may be consulted to advantage. 

Tumors of the Esophagus. — Cysts, papillomata, fibromata, lipomata 
and myxomata of the esophagus possess more pathological interest 
than clinical significance. 

The term polypus of the esophagus embraces pedunculated tumors 



.1800 



THE SURGERY OF THE ESOPHAGUS 



of various kinds, such as fibromata, fibrolipomata and myxomata, which 
arise in the submucosa and protrude into the lumen of the gullet. 
Thej' are usually found at the pharyn^-esophageal junction and near 
the bifurcation of the trachea. 

The polj-pi are, as a rule, pear shaped and rarely give rise to symp- 
toms, unless they grow to a large size. In this event, the lesion pre- 
sents the clinical picture of gradually in- 
creasing esophageal obstruction. The 
exact diagnosis may be made with the 
esophagoscope. Spontaneous avulsion 
of the tumor (during vomiting) has 
occurred (GobeP'). 

Carcinoma is by far the most frequent 
tumor met with in the esophagus. The 
growth may be primary or secondary. 
The latter occurs as the result of exten- 
sion from neighboring tissues ; actual 
metastases have not yet been reported. 

Carcinoma of the esophagus is usually 
of the flat cell variety, although colloid 
and cylindrical cell also occur. They are 
usually situated at the three points al- 
ready spoken of, i. e., opposite the cri- 
coid cartilage, at the bifurcation of the 
trachea, and near the .hiatus (Guisez,^"' 
Gottstein^^). According to v. Hacker,^^ 
the level of the bifurcation is its favorite 
seat. 

The chief symptom of carcinoma of 
the esophagus consists in difficulty in 
swallowing. As the growth infiltrates 
the gullet, it interferes with its contrac- 
tility, so that deglutition is obstructed to 

an extent out of proportion to the degree of stenosis. The symptoma- , 
tology of the affection is that of gradual obstruction of the esophagus, 
including pain and spasm, attended with gradual loss of weight out of 
proportion to the mechanical interference with deglutition. When the 
tumor is located in the neck, it may be palpated as a slowly increasing 
tender mass attended with enlargement of the lymph nodes. 

The diagnosis takes into consideration the clinical picture as stated, 




Fig. 849. — Carcinoma of 
Esophagus. 



THE SURGERY OF THE ESOPHAGUS 1807 

the age of the patient, and the esophagoscopic and Rontgenographic 
findings. The esophagoscope must be carefully introduced. If 
feasible, a section of the growth is removed for microscopical 
examination. 

The prognosis is unfavorable, even after extirpation of the growth. 
This gloomy outlook has been somewhat illuminated in cases of carci- 
noma of the upper esophagus by the radical work of Gluck.^® 

Extirpation of carcinoma of the esophagus is practiced in the man- 
ner already described in connection with operations on the neck and 
resection of the esophagus for stricture (p. 1799). The mortality of 
transpleural extirpation is 100 per cent. The palliative operative 
procedures are taken up in connection with strictures of the esophagus. 
Of these, gastrostomy is the most satisfactor3^ The use of the bougie 
is a dangerous maneuver. Local treatment of the lesion through the 
esophagoscope and the use of radium are of doubtful value. See 
chapter on carcinoma, Part VI. 

BIBLIOGRAPHY 

1. Jackson. Surg. Gjii. Obst., March, 1919. 

2. AcH. V. Bruns' Beitr., 1910, Ixx. 

3. Meltzer. Arch. f. Anat. u. Phys., 1883. 

4. Kreuter. Arch. f. elin. Chir., 1909, Ixxxviii. 

5. V. Hacker. Handb. d. prakt. Chir. ii, Stuttgart, 1913. 

6. Thomas. Lancet, 1904. 

7. V. Hacker. Beitr. z. klin. Chir., 1911, Ixxiii. 

8. HocHEXEGG. Wien. klin. Woch., 1912. 

9. Mackenzie. Dis. of the Oesoph., Loudon, 1894. 

10. Gerster. N. Y. Med. Jr. xv. 

11. Heurad. Arch. nied. beige., 1909. 

12. Killian. Miinch. med. Woch., 1910. 

13. Wood. Anns. Surgery, 1908. 

14. Gardere. Gaz. des hopitaux, 1910. 

15. GuiSEZ. Traite des mal de I' oesoph., Paris, 1911. 

16. Garde. These de Lyon, 1896. 

17. Newmann. See bibliogTaph of No. 5. 

18. Abbe. K Y. Med. Record, 1893, No. 25. 

19. Meter. Anns. Surgery, Ix. 

20. Heyrovsky. Wien.' kfin. Woch., 1911. 

21. V. Hacker. Arch. f. klin. Chir., 1908. 

22. Meyer. Jr. Araer. Med. Assoc, 1911, Ivi. 

23. Trendelenburg. Miiuch. med. Woch., 1909. 

24. Bircher. Zentrbl. f. Chir., 1907, No. 51. 

25. Roux. Semaine medic, 1907, No. 4. 

26. WubLSTEiN. Deutsch. med. Woch., 1904; Zentrbl. f. Chir., 1908. 

27. GoTTSTEiN. Surg. Cover, 1908. 

28. Kauffman and Kienbock. Wien. klin. Woch., 1911. 



1808 THE SURGERY OF THE ESOPHAGUS 

29. Lerche. Amer. Jr. Med. Sci., 1912. 

30. Erdmann. Anns. Surgery, 1906. 

31. LOTHEiSEN. Arch, f . klin. Chir., 1903 ; Zentrbl. f . Chir., 1908. 

32. BuTLiN. Brit. Med. Jr., 1893-1898-1903. 

33. Lexer, Quoted by Jurasz, in v. Bruns' Beitr., 1911, Ixxi. 

34. Pitt. Brit. Med. Jr., 1896. 

35. Starck. Die Divertic, etc., d. Speiserohre Halle, 1911. 

36. Spivek. N. Y. Med. Jr., 1910. 

37. Gobel. Deutsch. Zeitschr. f. Chir., 1904, Ixxv. 

38. Gluck. Handb, d. spec. Chir. des Ohres, etc., iv. Wiirzburg, 1913. 



PART XV 
SURGERY OF THE THORAX 



CHAPTER I 

INJURIES AND DISEASES OF THE THORACIC WALL 

The congenital deformations of the shoulder girdle and the vertebral 
column and their influence upon the contents of the thorax have been 
made the object of careful clinical study b,y the orthopedist (Chas. 
Fere et Schmid/ Ebstein-). This aspect of the problem is taken up 
in connection with the Surgery of Deformities, Part VIII. 

INJURIES OF THE THORAX 

Contusion of the Thorax. — Contusion of the thorax without apparent 
serious injury to the chest wall is of importance because of the injury 
to the thoracic contents likely to occur in this connection. These vary 
from a small rupture in a lobule of the lung to more or less severe 
trauma to the heart and great vessels. The lung and pleura are most 
often involved. The mechanism which produces the interthoracic 
injury is explained on the basis that the air does not escape through 
the glottis with sufficient rapidity to permit the thoracic contents to 
adapt itself to the forcible compression produced by the trauma 
(Koenig^). 

The clinical picture varies with the degree of intrathoracic injury, 
being that of hemothorax, pneumothorax and hemopneumothorax. 
Rupture of the diaphragm allows the abdominal contents to prolapse 
into the thorax and this may be attended with the symptoms of intes- 
tinal obstruction, though not infrequently the condition remains undis- 
covered until autopsy. A certain number of cases develop so-called 
contusion pneumonitis, which runs a mild course unless an infection 
develops, and then the picture is that of infectious pneumonitis and all 
its attendant complications. Rupture of the lung may be attended 
with traumatic emphrjsema (p. 560). This may be limited to the face 
and neck and upper part of the chest and is explained by the fact that 
the veins in this region do not possess valves (Perthes*). Hernia of 

1811 



1812 SURGERY OF THE THORAX 

the lung may occur without fracture of a rib. Tlip mortality from 
severe contusions of the chest is liigh. 

The treatment of contusion of the thorax varies in accord with the 
symptoms. Absolute rest in the horizontal position is essential. The 
administration of small doses of morphia is advisable. Shock is treated 
in the usual way (p. 945). Large effusions of blood are removed b}' 
aspiration. The value of thoracotomy for the purpose of arresting 
bleeding in subcutaneous rupture of the lung is not yet established. 
However, recent observations would seem to justify its employment in 
selected cases. 

Concussion of the Thorax. — Trauma to the thorax without any 
changes in its walls or contents may be attended with a clinical picture 
to which the term concussion of the thorax is applied. As a rule, the 
condition is ascribed to shock. However, there seems to be no doubt 
that trauma applied to this situation is occasionally attended with 
results ascribablo to lowering of the hlood pressure and to direct irrita- 
tion of the vagus. The causative force may produce direct concussion 
of the heart, which then presents the manifestations coincident with 
vagus irritation and is arrested in diastole. Persistence of lowered 
blood pressure indicates concussion of the depressor nerves and of the 
sympathetic nerve. 

Menacing symptoms or a fatal issue following a blow upon the 
thorax, especially upon the precordial region, may, in certain instances, 
be properly ascribed, jfirst, to heart failure, the outcome of intra- 
thoracic irritation of the vagus, and, later, to the lessening of the 
tone of the peripheral circulation. 

The prognosis is, as a rule, not unfavorable. The treatment consists 
in placing the patient in the recumbent position, followed bj^ artificial 
respiration, and stimulation. Elevation of the limbs, with a view to 
increase the quantity of blood in the thorax ( autotransf usion ) , is 
advised by Riedinger.^ 

Non-penetrating ivounds of the thorax are of importance because of 
the necessity for differentiating them from the penetrating. In stab 
ivounds and gunshot icounds this is not always easy. In doubtful cases 
drainage should be employed and the wound lightly tamponed. Em- 
bedded projectiles are best removed. 

Of the complications, injury to the internal mammary artery is of 
great importance. The vessel runs about 1 cm. external to the edge of 
the sternum. As a rule, the pleura is punctured, but this is not by any 
means always the ease. The wound must be enlarged and the bleeding 



INJURIES AND DISEASES OF THORACIC WALL 1813 

ends of tJie artery tied, li' this is not feasible, tamponade for ten days 
may be practiced. The intercostal arteries are treated in a similar 
fashion. 

Fractures of the sternum and ribs are taken up in Part IV, 
chap. iii. 

INFLAMMATORY DISEASES OF THE THOEACIC SKELETON 

Hematogenous Osteitis and Periostitis of the Ribs and Sternum. — 
Acute osteomyelitis of the bones of the thorax follows the laws of locali- 
zation laid down in the general part of this book (Part 11, chap. ii). 
Excluding the vertebrae, the ribs are more often invaded by the bac- 
teria of acute infectious diseases than are the other bones of the body. 
Typhaid osteomyelitis is very common. 

Acute osteomyelitis of the ribs presents the clinical picture of an 
acute infectious osteitis. The local symptoms usually begin at the 
metaphyses. The diagnosis must take into account similar infectious 
processes of the soft parts. The treatment consists in early resection 
of the infected bone. 

Typhoid osteitis and chondritis of the rihs deserve special mention. 
They usually develop during the convalescent period of so-called 
typhoid fever and may be a mixed infection. In a certain number of 
cases the typhoid bacillus is crowded into obscurity by the more aggres- 
sive pyogenic bacteria. While the process usually exhibits a tendency 
toward chronicity and presents a clinical picture not unlike that of 
bone tuberculosis, the domination of the mixed infection gives rise to 
acute exacerbations of the lesion. 

Acute osteomyelitis of the sternum is of importance because of the 
danger of secondary- involvement of the mediastinum. This urges 
prompt subperiosteal resection of the infected bone and the establish- 
ment of free drainage. 

Tuberculosis of the rihs and the sternum may appear by itself or 
may be associated with tuberculosis of other bones of the body. The 
latter condition of affairs occurs in 70 per cent of the cases (Koenig''). 
A considerable number of cases are the result of extension from tuber- 
culosis of the vertebrae, pleura, and lung. 

The primary hematogenous focus usually appears as a localized 
process which soon undergoes caseation or sequestration. The super- 
imposed soft parts are involved in the form of a cold abscess which 
breaks down, leaving one or more fistulous tracts communicating with 
the bone lesion. 



1814 SURGERY OF THE THORAX 

Tuberculosis of the sternum presents a similar picture and very fre- 
quently extends to the sternoclavicular articulations. It shows a tend- 
ency toward sequestration, so that occasionally the entire manubrium 
breaks down. Perforation into the mediastinum occurs, but is rare. 

The clinical picture of tuberculosis of the sternum and ribs is that 
of a chronic inflammatory process. In many instances a spindle 
shaped enlargement of the bone is the first evidence of the lesion. The 
lesion may remain at this stage for a long time. However, it usually 
breaks down, forms a cold abscess, and later establishes the usual 
sinuses. 

The diagnosis, in the early stages of the disease, may not be clear, 
especially when the lesion is restricted to a small area of thickening 
of the atfected bone. In these instances the microscope (aspiration), 
the Rontgcnogram, serological examinations, and exploratory^ incision 
must be sequentially employed. When the lesion breaks down, the 
diagnosis is no longer in doubt. The prognosis depends upon the 
underlying causative factor. 

The conservative treatment of tuberculosis of the thoracic skeleton 
in children is permissible. See Bone Tuberculosis, Part II, chap, 
xxiii. In the adult, radical excision of the focus is indicated. 

Luetic inflammations of the thoracic slieleton appear with all the 
landmarks of osteochondritis luetica. However, there is little to dif- 
ferentiate the process from tuberculosis. Of the diagnostic methods, 
other than the serological and microscopical findings, the therapeutic 
test is the most valuable. The treatment, other than medication, con- 
sists in resection of the affected bone. 

Actinomycosis of the thoracic wall presents the clinical picture of a 
hard, chronic, inflammatory, infiltrating process, usually attended with 
the formation of multiple fistulae. The diagnosis is made certain by 
the microscopical findings (Part II, chap. xix). 

Intercostal Neuralgia.^ The surgical significance of intercostal 
neuralgia, aside from that taken up in connection with the surgery of 
the spine (Part IX, chap, iii), lies in the causative relationship of 
pressure upon the nerves due to fractured ribs, osteomj'elitis, tumors, 
etc., the removal of which affords relief. In a certain number of cases, 
in which it is not feasible to remove the cause, extirpation of the nerve 
is permissible. This is easily accomplished by lifting the nerve from 
its bed at the lower border of the rib and extirpating it in the manner 
described in connection with the superficial branches of the trigeminus. 
The uncertainty of the operative outcome has led to the employment 



INJURIES AND DISEASES OF THORACIC WALL 1815 

of the subcostal injection of 70 per cent alcohol or 1 per cent osmic 
acid solution — measures which are followed by relief in a large pcr- 
centay:e of the cases. 

Tumors of the Thoracic Wall. — Cysticercus cellulose is occasionally 
found in the musculature of the chest wall. It is usually not recog- 
nized until it breaks down. 

Echinococcus appears in the soft parts and in the bones of the 
thoracic wall. It presents the picture of a slowly growing tumor, the 
nature of which must be determined by the microscopical examination 
of the aspirated contents. The presence of eosinophilia and an unex- 
plained urticaria may lead to a suspicion as to the nature of the 
growth. 

Nevi and epithelial cysts do not present any regional peculiarities. 

Liponiata are the most frequent tumors of the chest wall, especially 
of its posterior surface. Solitary lipoma appears in the form of a 
pear shaped tumor, which is often pedunculated. It not infrequently 
undergoes degenerative processes, though malignant changes are ex- 
ceedingly rare. Lipomata of the axillarj^ region may contain rudi- 
mentary mammary gland tissue, in which event they become enlarged 
and tender during menstruation and pregnancy. Retromammary lipo- 
mata push the breast outward, sometimes to an astonishing extent. 
Tumors of this sort are easily extirpated. 

Fibromata, pure neuromata, hemangiomata, and lymphangiomata do 
not present regional peculiarities. Osteomata and chondromata are 
very rare. 

Chondromata usually arise at the costocartilaginous junction, and 
at the point of union of the manubrium with the gladiolus, or of the 
latter with the ensiform cartilage. They do not give rise to symptoms 
until pressure is made upon the intrathoracic structures. In the early 
stage of development they must not be confused with tuberculosis and 
lues. The differentiation is based on the Rontgenographic examina- 
tion. They are easily extirpated. 

Malignant Tumors of the Thoracic Wall. — Enchondroma can 
no longer be regarded as a benign tumor (Ribbert^). Enchondromata 
of the sternum and ribs are not recognizable as such, except upon 
microscopical examination. They appear in the guise of a rapidly 
growing tumor of the bone, which bears considerable resemblance to 
sarcoma. 

Primary sarcomata of the thoracic wall begin in the soft parts and 
in the honcs^ Those of the soft parts are comparatively rare. They 



1816 



SURGERY OF THE THORAX 



are usually of the melanotic or small round cell variet}', both of which 
soon form metastases and, even when extirpated early, have a tendency 
to recur. Most of the tumors spring from the fascia of the pectoralis 
major muscle. Secondary sarc&mata of the soft parts occur in connec- 
tion with sarcomatous processes located elsewhere in the body. 

Primarij sarcomata of the osseous structures of the thorax are of the 
usual periosteal and myelogenous, osseous and osteoid varieties. 

Periosteal sarcomata appear as spindle shaped or nodular masses 
continuous with the surface of the bone; they are likely to be very 
malignant. Those of the myelogenous form are somewhat less so. 
The latter often give rise to 
persistent intercostal neural- 
gia, the cause of which is not 
apparent until the process 
breaks through the bone. 

Sarcomatous ribs soon 
fracture. After this the 
process spreads very rapidly 
in all directions, invading 
the pleura, the lungs, the 
heart, etc. 

Pressure symptoms do not 
appear until the process has 
invaded the thoracic cavity 
and are in proportion to the 
extent of involvement. 

The diagnosis is not easy 
at first. It is based on per- 
sistent pain, increasing anemia, loss of weight, and the Rontgeno- 
graphic findings. Ultimately the malignant character of the process 
becomes manifest. 

Carcinoma of the thoracic wall, other than that developing in connec- 
tion with carcinoma of the breast, is rare. Perhaps the so-called 
"corset carcinoma" may be mentioned in this connection. Occasion- 
ally carcinoma of the mediastinum extends to the skin and other soft 
parts of the chest. 

The Technic of Resection of the Thoracic Wall. — The extirpation of 
malignant tumors of the chest wall without simultaneous removal of 
the contiguous pleura is rarely permissible. If possible, the probable 
extent of the operative measures should be determined before the 




Fig. S.jO. — Extensive Resection' or the 
Thoracic Wall. 

Defect covered with flap from opposite side. 



INJURIES AND DISEASES OF THORACIC WALL 1;]17 

attempt at (.'xtirpaliuii is made. This is true even in cases of tubercu- 
lous and luetic processes for relief of which the pleura and, perhaps, 
the lung must be invaded by the surgeon. 

While it is undoubtedly true that the thoracic cavity has been, and is, 
constantly successfully invaded without the protection of differential 
jircssure apj>iiratus, it is also true that employment of the latter sim- 
plifies very much the technic of the procedure and markedly lowers the 
mortality. If the operation is executed without pressure differences, 
an effort should be made to suture the lung to the opening in the wall 
of the thorax, or a flap taken- from- the contiguous tissues may be 
turned or slid into the defect (Riedinger^'^. 

When the principle of pressure differences (Sauerbruch'^) is em- 
plo3-ed, the skin and musculature are divided down to the ribs (differ- 
ential pressure 5 mm. Hg.) ; an intercostal space is rapidly opened and 
the entire sector of the thoracic wall, including the ribs and pleura, is 
quickl}^ excised. The intercostal vessels are now tied and the necessary 
amount of lung tissue is extirpated. By increasing the pressure to 10 
to 12 mm. Hg. the lung is forced into the defect in the chest wall and 
repaired by suture. The defect in the thoracic wall ma}" be closed in 
the manner shown in Fig. 850. Thus the formation of a secondary 
pneumothorax is obviated. Resection of the sternum and invasion of 
the mediastinum is executed in a similar manner (p. 1854). 

The acquired deformities of the thorax are taken up in Part VIII. 

BIBLIOGRAPHY 

1. Ch. Fere et Schmid. Jr. de I'anat. et phys. t., 29. 

2. Ebstein. Saoiml. klin. Vortr., 1909. 

3. KoENiG. Verb. Chir. Kong., 1905. 

4. Perthes. Deutsch. Zeitschr. f. Chir. 1. 

5. RiEDiNGER. Hantlb. d. prakt. Chir. ii, Stuttgart, 1913. 

6. KOENIG. Tuberc. d. mensch Gelenke, etc., Berlin, 1906. 

7. RiBBERT. Gescbwiilsts lebre, Bonn, 1904. 

8. Sauerbruch. Tech. d. Thorax-cbir., Berlin, 1911. 



CHAPTER II 

PNEUMOTHORAX 

As soon as contact between the surface of the lung and the thoracic 
wall is abolished, as happens when the latter is opened, the "retrac- 
tion capacity" of the lung is brought into play and the organ is 
drawn toward its hilus (it is said to collapse} and a pneumothorax 
is established. If the opening in the thoracic wall persists, an open 
pneumothorax exists; when the external opening is spontaneously or 
artificially closed, a closed pneumothorax is present. A similar condi- 
tion of affairs obtains when a solution of continuity in the lung occurs. 
The open pneumothorax is of especial surgical importance. 

The degree of dyspnea attendant upon unilateral pneumothorax 
is in a measure dependent upon the elasticity of the mediasti- 
nal wall. If this is not sufficiently resistant (mediastinal flutter), the 
function of the uninjured lung is seriously interfered with (from 
pressure). Grave disturbances do not always appear as the result 
of the establishment of a pneumothorax. This ha-s led to the erroneous 
belief that the condition is not dangerous. As a matter of fact, the 
reverse is true. Indeed, it is not improbable that the absence of seri- 
our disturbances is due to an anatomical peculiarity, such as adhesion 
of the lung to the parietal pleura or a particularly resisting mediasti- 
nal membrane (Sauerbruch'). 

The Prevention of the Consequences of Pneumothorax. — When the 
thoracic wall is opened the disturbances consefjuent to pneumothorax 
may be abolished by grasping the lung with forceps and drawing it 
into the wound. This prevents fluttering of the mediastinal wall. 
When the thorax is accidentally opened during an operation, the 
wound is immediately sealed by suture. As already stated, after re- 
section of the thoracic wall, the lung may be sutured to the edge of 
the defect. There is no doubt that a persistent, closed pneumothorax 
is especially susceptible to infection (NotzeP). 

A number of methods devised to obviate the persistence of pneumo- 
thorax found their circulation in the establishment of the principle of 

1818 



PNEUMOTHORAX 1819 

maintaining the normal negative pressure, which prevented, tiie lung 
from retracting (Sauerbruch^). The basic theory of the procedure is 
to keep the lung inflated from the bronchial tree by suction upon its 
surface. The desired end may be attained by lessening the pressure of 
air on the surface of the lung — negative pressure — or by increas- 
ing pressure on the bronchial tree — positive pressure. 

It is certain that the methods prevent the development of pneumo- 
thorax. The lung on the opened side is made to functionate as a respir- 
atory organ. In practice, the pressure is never sufficient to interfere 
with aeration of the blood. In a general v^ay, it is justifiable to 

STATE THAT THE EMPLOYMENT OF DIFFERENCES IN PRESSURE PREVENTS 
THE CONSEQUENCES OF PNEUMOTHORAX IN A HARMLESS MANNER. 

The Sauerhruch cabinet may be described as follows: 
The cabinet is made of metal and glass and large enough to accom- 
modate an operator and two or three assistants. The patient's body 
lies upon a table with the head protruding through an opening in one 
side, guarded by a rubber collar which fits closely to the neck. The 
abdomen and lower extremities are covered by a canvas covered rub- 
ber sac which communicates by means of a tube with the outside air. 
This maintains the ordinary atmospheric pressure upon all parts ex- 
cept the thorax and upper extremities. Narcosis is administered under 
atmospheric conditions. The cabinet is well lighted and is provided 
with telephone connection. The air is exhausted from within and 
negative pressure produced by an electric suction pump. Later, a 
small, airtight anteroom was added, communicating with the main 
room and outside by airtight doors. As the suction pump communi- 
cates wnth this room, additional instruments may be called for, placed 
in this room, and, later, brought to the main operating room without 
affecting the air pressure. See Keen's Surgery, v. iii. When sufficient 
air is withdrawn from the cabinet to render the negative pressure equal 
to 10 to 12 mm. Hg., both pleural cavities may be opened without 
collapse of the lungs. With the aid of this apparatus extensive medias- 
tinal and esophageal operations may be performed, both pleural cavi- 
ties being opened without any of the deleterious effects or sequelae of 
pneumothorax. Sauerbrueh-'' reports sixteen intrathoracic and medi- 
astinal operations with most encouraging results, the fatalities in no 
instance being attributable to pneumothorax. Sauerhruch* at this time 
regards the employment of positive pressure face masks and intra- 
tracheal apparatus as of the greatest practical value in general sur- 



1820 SURGERY OF THE THORAX 

gical practice. He says that ' ' the positive pressure apparatus accom- 
plishes the purpose as well as the neg^ative pressure cabinet. ' ' 

F. T. Murphy^ uses an airtight helmet, inclosing the patient's head 
and neck, in which ether is administered and air pressure increased and 
maintained by water displacement. Green'' produces artificial respir- 
ation by a positive pressure plan, in which he uses the Hans Weger 
pump and his own etherizing apparatus and an intralaryngeal cannula. 
Janeway^ has devised a very elaborate etherizing apparatus, by which 
artificial respiration is maintained with the aid of an intratracheal 
tube (Fig. 86). Matas,^ Fell,'' Meyer," and Meltzer^^ overcome the 
effects of pneumothorax by a tightly fitting tracheal cannula or intu- 
bation tube and some form of air pump or bellows. 

BIBLIOGRAPHY 

1. Sauerbruch. Zentrbl. f. Chir., No. 6, 1904. 

2. NoTZEL. Verb. d. Deutsch. Gesell. f. Chir., 1906. 

3. Sauerbruch. Miinch. med. Woch., 1906. 

4. Sauerbruch. Handb. d. prakt. Cbir. ii, Stuttgart, 1913. 

5. F. T. Murphy. Boston Med. and Surg. Jr. xv. 

6. Green, Surg. Gyn. Obst. xv, 

7. Janeway. In Gwathmey's Anesthesia, New York, 1918. 

8. Matas, Trans. South. Surg, and Gyn. Assoc, 1899. 

9. Fell. Jr. Amer. Med. Assoc, 1891. 

10. Meyer. Arch, Exper. Path. u. Phar. Ivii. 

11. Meltzer. Same as No. 7. 



CHAPTER III 
PENETRATING WOUNDS OF THE THORAX 

The severity of penetrating wounds of the thorax is proportionate 
to the visceral damage and the elements of infection. Those involving 
the great vessels, the mediastinum, the roots of the lungs, the heart 
or the pericardium are usually promptly fatal. In diaphragmatic in- 
volvement the abdominal contents are likely to be invaded. The intro- 
duction of p3'0genic baceria at the time of injury results in the develop- 
ment of pyothorax. This may arise in connection with infection of 
the chest wall, or the infection may originate in the lung. Pneumonitis 
is a grave complication, regardless of the extent of the "S'isceral injur}'. 

Gunshot Wounds of the Thorax. — Gunshot wounds of the thorax 
usually involve the thoracic contents. Lilienthal and a number of 
coworkers make the following statement as expressing their con- 
clusions on war surgery: "The thorax is no longer a region where 
onU' a few dare to travel. Resection of a part, of a lobe of lung, 
suturing of wounds of the lungs and ligation of vessels are now 
common procedures. Thoracic explorations are made in doubtful 
cases, as are exploratory celiotomies. At the same time, the con- 
servative treatment of a certain variety of cases has been empha- 
sized." In this connection Bastianelli- says "Truly, for small punc- 
ture wounds produced by rifle bullets without severe bone lesions, 
the principle of expectation may be adhered to, at least with r^ard 
to life, but not always, if function is to be considered. Expectant treat- 
ment should be followed more rarely in shrapnel wounds, and even 
less frequently' for shell splinters." Experience in previous wars 
shows that the high velocity rifle bullet wounds offer a favorable prog- 
nosis in comparison with the older ones of low velocity and large 
caliber. In the latter, fragments of splintered ribs and clothing were 
introduced into the wound. Tliis gave a much larger percentage of 
infections with greater laceration of lung tissue and severe hemor- 
rhage and, because of the decreased velocity of the missile, it fre- 
quently remained embedded in visceral tissue. Because it forces ragged 

1821 



1822 SUKGERY OF THE THOKAX 

pieces of metal into the body the shrapnel used during the late Euro- 
pean war has caused severer wounds than the old slow velocity bullet. 
This is in a measure equalized by the present treatment of this type 
of wound. 

The symptoms of gunshot wounds of the thorax depend upon the 
direction of the penetration. Severe shack may exist with but slight 
visceral injury, and vice versa. The signs and symptoms of internal 
hleeding are indicative of the involvement of large vessels. Dyspnea 
may be due to air hunger from this cause, but is also indicative of 
pneumothorax or hemothorax-, pericardial or heart involvement. 

The diagnosis is not difficult. In the absence of subjective symptoms, 
examination reveals pneumothorax, emphysema, etc. Localized pain 
during respiration, with cough, is indicative of pleural involvement. 
Marked dyspnea, increased respiration, with absence of normal respira- 
tory sounds and hA'perresonance, indicate the entrance of air into the 
pleural cavity. Hemorrhage generally causes flatness at the base of 
the lung with loss of fremitus and respiratory sounds. Emphysema at 
the root of the neck is indicative of lung injury. Bloody, frothy ex- 
pectoration after attacks of coughing is diagnostic of a similar con- 
dition ; inrush of air may be heard on auscultation. In locating foreign 
bodies. X-ray and fluoroscopic examination are indispensable. 

The prognosis is not necessarily unfavorable, the outcome depend- 
ing upon the site of the injury and the visceral involvement. Injury 
to the heart and great vessels is usually immediately fatal. Operative 
treatment has greatly lessened the mortality. DuvaP saj^s "Alto- 
gether our personal statistics from the battle of the Somme, where, 
excluding operations of urgency, cases were treated medically, show 
a mortality of 20 per cent in three hundred cases. In a later series, 
subjected to operative treatment, of 136 cases (18 urgent and 118 not), 
the general mortality was 9 per cent. It will be seen*, therefore, that 
surgical treatment lowers the mortality very considerably, and that 
when septic complications do occur, they are less serious. 'In the 
above cases we had eleven cases of emphysema with one death." 

The menace of lung injury (except in large lacerations where the 
immediate prognosis is unfavorable) lies in infection and subsequent 
development of empyema, abscess and gangrene. The possibility of 
infection is always greater from an external wound than from one of 
the lung. If the wound is sealed, pneumothorax adds no great danger 
to the problem, as the air is readily absorbed. On the other hand, 
blood is taken up with much less certainty. 



PENETRATING WOUNDS OF THE THORAX 1823 

Crushing injuries with compound fractures of the sternum and 
ribs are especially dangerous. Lilieuthal^ says "The complication 
of fractured ribs may be considered one of the most dangerous of war 
wounds of the tiiorax. It almost invariably leads to infection, especi- 
ally when numerous spicula have penetrated the lung." 

The treatment of gunshot wounds of the chest is divided into the 
immediate and subsequent. The former includes the routine care of 
shock and hemorrhage and the latter the prevention of infection. 
Morphin is a useful agent when used with discretion. TTie external 
wound should be cleansed and a dry sterile dressing applied. The 
superficial wound is sutured only when the soft parts are extensively 
lacerated, and then must be drained. Fractured ribs demand strap- 
ping or the diachylon bandage. Pneumothorax, artificial or traumatic, 
often arrests severe pulmonary bleeding by contracture of the lung 
tissues upon the bleeding vessels. If hemorrhage continues, the pleural 
sac is widely opened and the ligature or tamponade is employed. 
Marked dyspnea calls for aspiration of the pleural contents. The 
treatment of infection is taken up on p. 1831. Rupture of the dia- 
phragm, with or without hemorrhage, should be repaired by thoraco- 
tomy (p. 1848). 

Gask* says "When a missile has traversed both the chest and 
abdomen, the diaphragm is necessarily injured and abdominal viscera 
may invade the pleural cavity. This is more common on the left side 
than on the right, as the latter is protected by the liver. Employment 
of the transpleural route in conjunction wnth the abdominal is at times 
necessary in order to repair the diaphragmatic rent. The w^ar has 
modified and perfected the teehnic of acute thoracic surgery and 
demonstrated the fallacy of the expectant plan of treatment. It has 
also emphasized the fact that a special differential pressure operating 
cabinet is not necessary in this class of cases." A special classifi- 
cation and outline of treatment in gunshot wounds is quoted from the 
report of Lilienthal,^ as follows: 

"Sucking wounds are those in which there is a free access of air to 
and from the interior of the chest. These wounds, when small, are 
not necessarily dangerous. Traumatic openings, however, when large 
enough to admit air by suction, in quantities as great as, or greater 
than, that which enters the lung through the larynx, give rise to 
mediastinal flutter with its attendant dangers. In these eases it is 
best to close the chest by simple skin suture or by firmly covering 



1824 



SURGERY OF THE THORAX 



the wound with wet gauze. If the wound is very large, the 
patient's distress, due to the mediastinal motion, may be instantly re- 
lieved by traction on the presenting lung (p. 1818). This steadies the 
mediastinum and the lung may be kept in contact with the chest wall 
by a few sutures or by a sterile safety pin. No great traction force is 
necessary. In from twenty-four to forty-eight hours the pleura cover- 
ing the mediastinum is stiffened by exudate, thus obviating the danger 
of 'flutter.' The presence of the exudate makes opening of the in- 
fected chest less dangerous than wounding of the normal thorax. 
Thoracotomy for empyema illustrates this relative immunity." 

Large sucking wounds presuppose gross injury to the lung and 
other structures, besides the 
probable implantation of in- 
fected materials, such as cloth- 
ing. Fifteen of these cases 
were treated by LilienthaP with 
six fatalities — a mortality of 
40 per cent. 

Penetrating wounds include 
those in which the missile is 
within the chest or in the thor- 
acic wall, having passed com- 
pletely through one wall of the 
cavity, but with no wound of 
exit. Out of thirty of this class 
there were nine deaths — a 
mortality of 30 per cent. 

Of completely perforating 
wounds with entrance and exit 
(no foreign body retained), out of twenty-one cases, two died. 

Lilienthal's summary of conclusions is as follows: "The wounds 
seen in evacuation hospitals may be divided in two classes: (1) 
Those which demand repair of obvious injuries to the chest wall, 
such as large open wounds or extensive fractures of the ribs with 
probable injury to the lung. (2) Injuries to the lung or large foreign 
bodies in the thorax which demand exploration. Wounds in class 1 
should be treated on ordinary surgical principles and the wound 
closed as well as possible. In the presence of large defects in the 
pleura obliteration may be accomplished by suturing the inflated lung 
to it. When this is not feasible, flaps may be used for the purpose. 




Fig. 851. — Lillienthal 'S Rib Spreader. 



PENETRATING WOUNDS OF THE THORAX 1825 



Wounds iu class 2 should be operated upon by what we have denomi- 
nated as major intercostal thoracotomy without resection of ribs. With 
the aid of a well constructed rib retractor (Fig. 851) an ample open- 
ing can be made, through which all parts may be clearly visualized 
and through which operations on the lungs, diaphragm, and most 
parts of the chest wall can be performed with comfort to the operator. 
In concluding the operation, the ribs may be easily brought together 
and the pleura fully approximated by three pericostal sutures of ab- 
sorbable material (kangaroo tendon or chromicized catgut). Whether 
or not there should be approximation of the skin is a matter to be 
decided in each case. 

"There may be combinations of class (1) and (2) by extending an 

already large wound in any part of 
the chest. The principle of visual 
exploration with the aid of a rib 
spreader can be applied here. 

''Some kind of forced anesthesia, 
such as the intrapharjmgeal method 
already referred to, is absolutely 
necessary in treating recent wounds 
of the thorax by full exploration. 

"All thoracic wounds were kept 
under observation for not less than 
ten days at the evacuation hospital, 
and even then, we were not sure 
that complications — mechanical or 
through infection — might not occur 
at a later period. 

"Pneumonitis of the opposite lung 
is the greatest immediate danger in these cases. Wliile'its cause was 
unknown, the patients were guarded against cold and exposure, espe- 
cially during the change of dressings." 

DuvaP states "My investigations show clearly that a gunshot 
wound of the lung presents exactly the same lesions as does any 
other war wound and is subject to the same evolution, 1. operations 
of urgency — (a) serious external hemorrhage; (b) open thorax and 
mechanical difficulties in respiration ; 2. early operations for wounds 
of the lung. 

"1(a). Serious external or internal hemorrhage calls for immedi- 
ate thoracotomy ; suture of the bleeding wound of the lung or ligature 




Fig. 852. — Control of Bleeding 
Vessel at Lower Edge of Kib. 



1826 SURGERY OF THE THORAX 

of the bleeding point. If the general condition of the wounded 
man allows, the complete surgical treatment of the wound of the lung 
and of the parietal wound, and complete closure of the chest after 
cleansing of the pleural cavitj^, are executed. 

"1(b). In open thorax some surgeons are content to suture the 
skin wound without treating the injury of the chest cavity. Statistics 
show that this method of combating asphyxia is good, but it does not 
protect the patient from those complications which follow the normal 
evolution of the lung wound, and the mortality of open chests treated 
by suture alone is about 20 to 24 per cent. In our opinion it is not 
logical to close the thoracic cavity without treating the wound of the 
lung and, even when the condition of the patient is serious, it is best 
to perform the complete operation. 

'^hi early operations for wounds of the lungs, apart from those of 
urgency, the indicadtions for operation are difficult to define. The 
following, however, may be cited : All foreign bodies retained in the 
lung, unless they are very small, should be removed. All wounds of 
the lung, complicated by a fracture of the ribs, should be operated upon, 
because they contain splinters of bone (intrapulmonary splinters are 
visible only by Rontgenography, and not b}^ the fluoroscopic screen). 
Every wound of the lung which, on fluoroscopic examination, shows a 
large intrapulmonary hematoma should be operated upon, because this 
hematoma almost always becomes infected. Even tangential wounds 
of the thorax with pulmonary lesion should be submitted to the same 
treatment. Apart from these cases, through and through wounds by 
rifle bullet without serious hemorrhage, and wounds containing very 
small fragments should not be operated upon. It is important to re- 
member, however, that the comparative freedom from danger in sur- 
gical intervention renders the indication for operation more and more 
frequent. 

"According to our latest statistics for operations not of urgency, we 
have operated upon eighteen cases out of one hundred and eighteen. 
The favorable time for operation upon the lung is as soon after injury 
as possible. After thirty hours it is, as a rule, advisable not to perform 
any operation. 

"In operations of urgency in cases with hemorrhage and open 
thorax, we have cured 66 per cent of our wounded. In thirty-five 
prophjdactic operations for infection of the lung and pleural cavity, 
there were no deaths." 

Bastianelli^ advises the production of an artificial pneumothorax 



PENETRATING WOUNDS OF THE THORAX 1827 



in lung injury in the majority of cases and even after other operative 
procedures have been performed. He advocates the use of the Morelli 
bags (Fig. 853) for occluding open wounds and the Morelli apparatus 
for production of artificial pneumothorax (p. 1847). 

Gask,* in speaking of types of wounds, says "The types of wounds 

which are most com- 
monly met with in 
the casualty stations 
are (1) through and 
through wounds 
caused by rifle bul- 
lets; (2) through 
and through wounds 
caused by shell frag- 
ments; (3) lodging 
wounds with reten- 
tion of large foreign 
bodies; (4) lodging 
wounds with reten- 
tion of small foreign 
bodies; (5) open 
sucking wounds of 
the thorax with or 
without retention of 
foreign bodies. 

''Indications for 
early operation are: 
a ragged wound of 
the soft parts ; bleed- 
ing from the parietal 

Fig. 853.— The Upper Eubber Bags Are used to Plug wound ; compound 
A Chest Opening. The Lower Eubber Bags, with fracture of the ribs • 

suction of air into 
the pleural cavity ; 
retention witliin the chest of a large foreign body ; great pain due to 
indriven splinters of bone ; rapidly increasing pneumothorax, due to a 
valve-like opening in the pleural cavity which allows air to be sucked 
in and prevents expulsion ; and a large hemothorax which cannot be 
evacuated by aspiration. When none of these indications is present, 
that is, when the wounds of the chest wall are small and clean, such as 




Interior Drain Are for Suction Treatment of 
Empyema (Morelli). 



1828 SURGERY OF THE THORAX 

are made by a rifle bullet, when the ribs are not splintered, and when 
the foreign body retained is small, the i)atient is treated on general 
medical principles." 

Turner'^ says in his summary "The indications for operation in 
late cases, are as follows: 

"1. Foreign bodies in the parieties with, or without, sinuses. 

"2. Foreign bodies in the lung, irrespective of size, if associated 
with persistent cough, hemorrhage or suppuration. 

"3. Large foreign bodies in the lung, even if the symptoms are 
purely nervous. 

''4. All foreign bodies lodged in the pleura with, or without em- 
pyema. 

"5. All cases of infected hemothorax. 

"6. All cases of through and through wounds with shrinking of 
the side, lessened lung expansion, and interference with movements 
of the diaphragm in which treatment by exercises, etc., has failed. 

Surgical Diseases of the Pleura. — Injury to the pleura has been dis- 
cussed in conjunction with penetrating and crushing wounds of the 
chest and pneumothorax. 

Air may enter the pleural cavity from penetrating wounds of the 
chest, lung perforations, trauma, rupture of a tuberculous cavity and 
in connection with infection with aerogenes capsulatus in the pleural 
exudate. 

Hydrothorax is a transudation. The fluid is a clear straw color 
and does not contain fibrin or bacteria. It appears as a part of gen- 
eral anasarca which may be due to cardiac decompensation, renal in- 
sufficiency or hemic conditions. It becomes surgical when caused by 
inflammatory diseases of the pleura, b}- new growths or trauma, in 
accord with v.iiich the fluid takes on different characteristics depend- 
ing upon w^hether it is due to hemorrhage or infection. In these in- 
stances the condition of the fluid changes and, strictly speaking, they 
should be termed hemothorax or pj^othorax, as the case maj^'be. The 
effusion is usually bilateral, diminishing the thoracic cavity and caus- 
ing displacement of the lung and heart. According to Stengel,® uni- 
lateral effusion usually follows cardiac disease. The hydrothorax in 
these cases is, as a rule, right sided and is probably due to pressure 
upon the azygos veins and root of the right lung. 

Dyspnea, if associated with cardiac or renal disease, arouses sus- 
picion of the effusion. The physical signs depend upon the amount 
of effusion. Inspection reveals bulging of the intercostal spaces; pal- 



PENETRATING WOUNDS OF THE THORAX 1829 

patioti, absence of fremitus; percussion, flatness; and ausculation, 
absence of respiratory sounds and vocal fremitus. 

The surgical treatment consists in aspiration of the fluid. This must 
often be repeated. Permanent drainage is rarely necessary. 

Hemothorax designates free blood in the pleural cavity. It is caused 
by wounds of the chest, rupture of an aneurism, and new growths of 
the pleura. In the last condition the effusion is hemorrhagic, but may 
be serous at first. In the absence of infection tJie blood is usuall}^ ab- 
yorbed. In traumatic cases the onset may be insidious, but one should 
be alert for signs of hemorrhage. In ruptured aneurism, the hemor- 
rhage is fatal. The signs are those of fluid in the chest plus those of 
hemorrhage, the degree depending upon the amount of bleeding. 

The prognosis depends upon the cause. In traumatic cases, the size 
of the vessel, its location and the possibility of ligature of the bleeding 
vessel (if spontaneous clotting does not occur) are deciding factors. 

The treatment consists in absolute rest in bed, morphin (or panto- 
pin), chest strapping or diachylon bandage, ice bag. etc. Arrest of 
the bleeding by ligation, cautery-, or packing is indicated. See Gunshot 
Wounds, etc., p. 919. 

Chylothorax may be defined as a collection of chyle in the thoracic 
cavity. It is due to injury to the thoracic duct, especially in gunshot 
wounds. Several cases have been reported following suppurative or 
malignant disease. The chyle empties into the mediastinum from 
the pleural cavities when a communication exists between them. Chylo- 
thorax usuall}' escapes recognition in traumatic cases, the other vis- 
ceral injuries and hemorrhage overshadowing the injury to the duct. 
If the duct involvement is the important injury, gradual accumulation 
of fluid in the chest cavity, and progressive loss of weight and diges- 
tive disturbances are the important symptoms. A positive diagnosis 
can be made only by aspiration. 

If the duct does not heal spontaneously, the prognosis is unfavorable, 
as operative measures do not afford relief. Repeated aspirations have 
been followed by recovery in a few cases. The outcome depends, to 
a large degree, on the size and character of the injury to the chest. 

Pyothorax is an accumulation of pus in the pleural cavitj'. It is 
produced from without by infected penetrating wounds ; from within, 
by pneumonitis, abscess of the lung, mediastinal or subphrenic suppu- 
ration, and also by an infected focus in the chest wall, and may be 
hematogenous in origin. In most cases of empyema the exudate is 
at first serous, and, later, purulent, in character. In penetrating 



1«30 SURGERY OF THE THORAX 

wounds, however, the fluid is purulent from the beginning. The serous 
fluid is straw or amber colored, after a time becoming cloud}", and 
finally opaque. The organism responsible for the infection has some 
bearing on the color and consistency of the fluid. The pneumococcus 
produces a thick, creamy, yellow or greenish pus; the streptococcus, 
a watery and flocculent pus; the tuberculous variety, a thin fluid 
containing numbers of caseous masses. The odor is at times nauseat- 
ingly sweet ; following external wounds it is fetid. The colon bacilli 
produce a foul-smelling pus, while cases secondary to gangrene of the 
lung have a putrid odor. The fluid usually separates into a clear 
upper, and a creamy lower, layer. 

The pleural surfaces are greatly thickened and are more or less 
covered by a fibrinous exudate. If accumulation of pus is limited by 
adhesions, a sacculated empyema is developed. This may be interlobar 
or located between the diaphragm and the base of the lung. 

Empyema may terminate by absorption of the fluid (if the amount 
is smallj ; b}' rupture into the esophagus or stomach; by external 
rupture, through an intercostal space; or it ma}' erode a bronchus, 
causing immediate or subsequent suffocation ; or, like a tuberculous 
abscess of the spine, point at the groin. Finally death occurs by ex- 
haustion frcjm toxemia and embarrassed respiration. 

The symptoms may develop insidiously or the onset may be sudden. 
They may be those of a .simple effusion with compression, to which are 
later added those of septicemia, or those of sudden compression with 
marked toxemia. With an insidious onset, the clinical picture may 
simulate a pulmonary or abdommal condition; and embarrassed respir- 
ation, intercostal bulge, and irregular remission of temperature may 
not occur until later. In some cases chills and sweats are the initial 
symptoms. Leukocytosis depends upon the type of organism. The 
physical signs are tho.se discussed in simple effusion. The dispropor- 
tion in the two sides of the chest, together with the intercostal bulge, 
is especially noticeable in children. 

In clearly defined cases the diagnosis is easy. When the onset is in- 
sidious the condition may be overlooked. Aspiratimi is often necessary 
before a positive diagnosis can be made. The X-ray is of great value 
in localization, especialy in the sacculated variety. 

The prognsois varies with the type of causative organism; in pneu- 
mococcus empyema it is generall}^ good. The toxemia accompanying 
streptococcus and staphylococcus infections makes the outlook unfav- 
orable; this is also true with regard to the tuberculous type of the 



PENETRATING WOUNDS OF THE THORAX 1831 

affliction. Empyema following rupture of a subphrenic abscess and 
gangrene, or abscess of the lung, is usually preceded by a period of 
exhaustion which renders the outcome unfavorable.. 

The treatment, except in the tuberculous variety, is operative. This 
should be executed as soon as the diagnosis is made. The exact location 
of the exudate should be verified with the aspirating needle imme- 
diately before the thorax is opened. Aspiration in certain cases of 
pneumococcus empyema, in which the pus is sterile, may be followed 
by relief. 

Mozingo" uses what he calls the closed method with Dakin 's solution. 
For the purpose the apparatus of Morelli (p. 1847) may be used. 
Mozingo' makes the following statements : 

"1. Early operation b}- the closed treatment method has the fol- 
ing advantages: 

"(a) It can be done without shock to the patient or 

collapse of the lung. 
"(b) It provides perfect evacuation and cleansing of 

the emp3'emic cavity. 
"(c) It prevents absorption of toxins. 
" (d) It prevents the lung, compressed by the exudate, 
from becoming fixed in compression. 
"2. Sterilization is more rapid by the closed, than by the usual, 
methods, as the antiseptics are held in contact wdth the 
infected surfaces until they have exerted their full bac- 
tericidal action. 
"3. Dakin 's solution followed by a two per cent dilution of liquor 
formaldehyd in glycerin is the most ideal antiseptic method 
of treating empyema. 
"4. Communication of an empyemic cavity with a bronchus is 
more common than is generally suspected. It is not a 
contra-indication to the use of Dakin 's solution and formal- 
dehyd, and closes more readily when these are used. 
"5. Constant negative pressure gives the maximum expansion of 
the lung, a-nd the irritating and cleansing action of sodium 
hypochlorite solution causes rapid obliteration of the cavity. 
"6. In uncomplicated cases of empyema the patient need not be 

kept in bed. 
"7. Test smears are negative, although cultures are positive when 
Dakin 's solution is used, and vice versa when f ormaldehyd- 
glycerin is employed. 



1832 SURGERY OF THE THORAX 

"8. Rontgenographic and bacteriologic laboratory facilities, while 
always to be preferred, are not absolutely essential in treat- 
ing empyema by the closed method. 
"9. The closed method is productive of great economy of time, labor 

and dressing material. 
"10. Treatment b}' the closed method can effect cures in many cases 
similar to those that are usually treated by the Schede, 
Eastlander or Delorme operations. 
"11. The closed method is practicable in the home and country 

practice. 
"12. A hypochlorite solution- of increased strength over Dakin's 
solution, in both alkalinity and available amount of chlorin, 
can be used in empyemic cavities with safety. ' ' 
The writer feels that Mozingo "preaches a heresy." The concep- 
tion of the method cannot be based on the diverse pathological con- 
ditions present in cases of empyema. However, experience may prove 
the contrary. 

The technic of thoracotomy is described farther on (p. 1849). After 
the pleura is opened the exudate is gradually allowed to escape, the 
rate of outflow being controlled with a wet pad. The condition of 
the cavity may then be explored with the gloved finger. 

A drainage tube is inserted and Bryant's* "bull dog" — a post- 
operative aspiration apparatus — may be attached to the drainage tube, 
or a simple double tubed bottle may be connected with it. The dress- 
ing should be changed frequently. Irrigation has its limitations. It 
may be used, however, when drainage is obstructed by necrotic tissue. 
A two per cent liquor formaldehyd in glycerin may be employed for 
the purpose. Dakin's solution has recently become en vogue and good 
results have been reported; Dakin's in combination with the former 
has also produced good results. 

In early cases removal of pus is followed by immediate expansion 
of the lung. Later, when organization has taken place, the expansion 
may be aided by having the patient blow on a trumpet or a bugle. 
This method has come into prominence during the war. A good sub- 
stitute is making soap bubbles with an ordinarj^ clay pipe, or using 
"Wolff's bottles (Fig. 854), where fluid is tran.sferred from one bottle 
to another by blowing. In early cases Bryant's^ "bull dog" works 
exceptionally well. In late cases, where fibrinous organization has oc- 
curred and the collapsed lung is bound down by a thick fibrinous exu- 
date, Fowler^ and Delorme" advise opening the thoracic cavity freely 



PENETRATING WOUNDS OF THE THORAX 1833 

by an osteoplastic flap and removing fibrinous exudate from the vis- 
ceral la^'er of the pleura. 

An immediate partial, and later complete, expansion of the lung 
may occur. If this fibrinous exudate is not removed, the lung under- 
goes a cirrhotic change which prevents expansion and the suppurative 
pleural cavity persists. As the lung cannot expand, several operations 
have been devised to approximate the chest wall to the lung. 




Fig. 8.j4. — Wolff 's Bottles. 
(From Keen's Surgery, copyright by W. B. Saunders Co.) 

Estldnde7''s^'^ operation is performed in cases w^here the cavity 
is small. It consists in removing several ribs, leaving the periosteum 
and soft parts intact, and allowing the collapse of these parts, thus 
obliterating the hollow space. In the larger type of cavity this method 
is inadeqate, owing to the stability of the intercostal muscles and 
periosteum (p. 1852). 

Schede's^^ operation, which is largely practiced, consists in the 



1834 SURGERY OF THE THORAX 

complete removal of ribs and intercostal muscles, leaving a flap of 
skin, fascia, and superficial thoracic muscles, which is sutured in place 
and made to lie in contact with the collapsed lung (p. 1852). 

The surgical treatment of tuherculaus eriipyenm is a debatable ques- 
tion. As the pus rarely gives rise to severe toxemia, and mixed infec- 
tion, with its toxic s^Tidrome, almost always follows the operation, it 
is best to withhold interference until the symptoms become menacing. 
In this event, asepsis must be carefully practiced. Aspiration, and, 
later, injection of emulsion of iodoform is the method of choice. 

New Growths of the Pleura. — Primarj- growths of the pleura are very 
rare and are of mesoblastic origin. The secondary growths are more 
frequent and follow direct extension from the lung, the mediastinum 
or chest wall. They are also metastatic in origin. 

Primary Growths of the Pleura. — Endothelioma appears as a 
diffuse growth or in the form of nodules. Effusion may occur and is 
likely to be, though not necessarily, tinged with blood. The tumors de- 
velop insidiously, and, when sjTnptoms are present, simulate pleurisy 
with effusion; pain, when present, is no different from that accom- 
panying dry pleurisy. The diagnosis is made by aspiration and resis- 
tance of tissue. The physical signs remain practically the same after 
the fluid is removed. Blood tinged fluid is indicative of new growth. 

Sarcoma of the pleura simulates endothelioma, being single, mul- 
tiple and diffuse. As elsewhere in the body, its growth is rapid and 
bloody fluid is more likely to be present than in endothelioma. Rapid 
afebrile accumulation of fluid without apparent cause is of diagnostic 
value. X-ray is helpful, though it does not differentiate lung growths. 
Microscopical examination of the aspirated fluid may lead to a con- 
clusion, especially when it contains mitotic figures. 

Secoxdart Growths. — Carcinoma and sarcoma occur more fre- 
quently and give practically the same signs and s^Tnptoms as primary 
growths. The diagnosis in this class of cases is less difficult when the 
primary growth is recognized elsewhere. The nature of the growth 
and its location usually limits the treatment to aspiration, X-ray and 
radium. In secondare- growths which spread by direct extension from 
the chest wall, surgical extirpation is possible. 

BIBLIOGRAPHY 

1. Ln.iEXTHAL et at. Jr. Amer. Med. Assoc, 1919. 

2. Bastiaxelli. Surg-. G>ti. Obst. xxviii. 

3. Duval. Surg. Gyn. Obst. xxviii. 



PENETRATING WOUNDS OF THE THORAX 1835 

4. Gask. Surg'. CJyu. Obst. xxviii. 

5. Turner. Surg. Gyn. Obst. xxviii. 

6. Stengel. Text Book of Pathology, 1910. 

7. MoziNGO. Jr. Amer. Med. Assoc. Ixxi, 1918. 

8. Bryant. Op. Surg, i, N. Y. 1905. 

9. Fowler. N. Y. Med. Kecord, 1893. 

10. Delohme. Gaz. d. Hop., 189G. 

11. Estlander. Rev. mer. de med. et de chir., 1877. 

12. Schede. Verli. d. Cong-, f. innere Med., 1890. 



CHAPTER IV 
SUEGERY OF THE LUNG 

Injuries of the lung have been taken up in connection with those of 
the chest Avall (p. 1816). 

Surgical Diseases of the Lung. — Abscess of the lung is comparatively- 
rare. Its etiological factors are numerous. It occurs most often as a 
sequel to bronchopneumonic infections. It may follow the lodgment 
of foreign bodies in a bronchus, hemorrhagic infarcts with infection, 
perforating empyema, infected penetrating wounds, and it may be 
hematogenous. The abscess, as a rule, is single, the invading organism 
depending upon the primary cause, i. e., secondary to pneumonitis 
(pneumococcus), secondary to pyogenic infection (staphylococcus, 
streptococcus), etc. Mixed infection is the rule. 

The sudden onset of the symptoms of fever, following pneumonitis, 
without additional signs of lung involvement should arouse suspicion 
of abscess. This is made certain by the expectoration of a large amount 
of foul smelling pus. When the cause is other than pneumonitis, the 
history of the case must be taken into account. If rupture into a 
bronchus is delayed, the physical signs are those of the first stage of 
pneumonitis. After rupture, physical signs of cavitation appear, with 
sibilant and sonorous rales and amphoric breathing. Localization by 
physical signs is often misleading, especially if the abscess is of the 
central tj^pe. The X-ray findings are helpful. Exploratory aspira- 
tion should be employed only if the surgeon is prepared to operate 
at once. 

The prognosis of abscess, if drained without infecting the pleural 
cavit.y, is, as a rule, favorable. 

When the abscess is located it is exposed by thoracotomy. The 
presence of pus is determined with a director and the opening en- 
larged with bUmt scissors or an artery clamp. If the process is at- 
tacked before adhesions are formed, this may be overcome by Keen's^ 
method which he describes as follows: "A rectangular flap is made 
by an incision 5 to 6 cm. long in the axis of a rib and two short vertical 

1836 



SURGERY OF THE LUNG 1837 

incisions at each end. This exposes one, or, if the lateral incisions are 
made suliHcieutly long, two intercostal spaces. By light touches of the 
knife the intercostal muscles are gradually divided and pushed up and 
down until the parietal pleura is reached. If there are no adhesions, 
the mottled surface of the lung can be seen moving up and down with 
each respiration. If adhesions exist, the pleura is opaque and no such 
motion is seen. In order to produce adhesions it is necessary only to 
pack the wound for three or four days with iodoform gauze and hold 
the flap in place by a few temporary sutures. The abscess can then, 
be opened without danger of infecting the pleura." 

When rupture into a hrouchus occurs, the question of external drain- 
age is a debatable one. In a certain number of cases healing occurs 
spontaneously. Delay in healing is due to the formation of strong ad- 
hesions of the lung to the chest wall so as to prevent collapse of the pus 
cavit}' after spontaneous drainage is complete. Murphy^ advocates 
production of a pneumothorax W'ith nitrogen gas when no adhesions 
are present, and thoracotomy and breaking down of adhesions, if any 
be present. He determines this point as follows : a hj^podermic needle 
is introduced over the site of the abscess and, w^hen the point is em- 
bedded